Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a non-invasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a NIV. You say that the enrollee has a neuromuscular 
disease, and she has been using the trilogy and benefiting from the device. It is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for continued use of a NIV is not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued use of a NIV. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has multiple 
sclerosis, severe obesity, and obstructive sleep apnea. The enrollee has had a home ventilator since September 
2022. On the most recent visit with the pulmonologist on June 20, 2023, spirometry was normal, with a forced 
vital capacity of 80% of predicted. The normal spirometry indicates this enrollee does not have substantial 
impairment of diaphragm function due to the multiple sclerosis.  There is no diagnosis of COPD, thoracic 
restrictive disease, or other neuromuscular disease. The enrollee does not meet Medicare criteria for a 
respiratory assist device or a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) months of continued use of a non-invasive ventilator (NIV) (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92950 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for procedure code 92950. You say that these services are separately payable. The 
Plan denied your request. The Plan says the payment for this service is included in the global surgery period for 
36589, which has a 10-day global surgery period and was provided to the enrollee on October 9, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a postoperative period of 10 days applies to some minor surgeries. The payment for the surgical 
procedure includes payment for all related care provided during the postoperative period. Modifiers 78, 79 and 
24 are used to report services performed by the same physician which are unrelated to the initial procedure and 
therefore require separate payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 37252 have not been met. Specifically, this service was performed by the same 
physician within the 10-day global surgery period of another procedure. This service was not billed with a 
necessary modifier to indicate that it is not related to and therefore not included in the payment for the previous 
procedure. Therefore, we decided that the Plan does not have to pay for procedure code 92950 billed for date of 
service October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on January 26, 2023, and 
February 2, 2023. 
 
You asked the Plan to pay for a core buildup. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup (D2950) provided on January 26, 2023, and February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the upgraded electronics are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have use of the upper extremities and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze for home use and Covid 19-sanitize (billed as D1999 
x2) 
 
You asked the Plan to pay for gauze for home use and Covid 19-sanitize . You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gauze for 
home use and Covid 19-sanitize (billed as D1999 x2)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve an office visit (99204).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022, billed with 
codes 81351, 81201, 81405, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022, billed with codes 81351, 81201, 81405, and 81406.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer-assisted surgical navigation MAKOplasty 
(0055T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of MAKOplasty for robotic assistance in 
the setting of total shoulder joint arthroplasty has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the existing literature does not show that Mako robotic total shoulder surgery has better 
outcomes than conventional open surgery. There is no medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computer-assisted surgical navigation MAKOplasty (0055T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoVive Plus Allograft (20930). 
 
You asked the Plan to pre-approve OsteoVive Plus Allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the medical necessity for the denied procedure/services has not been 
established after clinical review and per the peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve OsteoVive Plus Allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OsteoVive Plus Allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve OsteoVive Plus Allograft (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that the inpatient admission is not 
medically necessary. The Plan denied your request. The Plan says you are requesting reconsideration of the 
denied authorization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that a post-operative inpatient stay is not necessarily anticipated to be over two 
midnights after a shoulder arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard (D5212) for tooth ##22. 
 
You asked the Plan to pre-approve the dental service. You say that the previous dentures were poorly made and 
it is medically necessary for your health to replace the dentures and implants. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of September 20, 
2022. Therefore, we decided that the Plan does not have to pre-approve the occlusal guard (D5212) for tooth 
##22.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fender light assembly (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested accessory does not serve a medical purpose and cannot be 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a fender light assembly (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the upgraded electronics are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have use of the upper extremities and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guidance radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the requested treatment is medically necessary. The 
Plan denied your request. The Plan says the requested treatment is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize 
the target to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when 
generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of 
normal tissues exposed to radiation. Usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) 
approved for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but 
simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple 
simulations (77280- also requested in this case) and/or IGRT for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general) is not necessary. The decision is unfavorable as billing for daily IGRT 
which would not be "furnished in accordance with accepted standards of medical practice". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guidance radiation therapy (IGRT) (G6001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the biopsy of oral tissue (D7286) provided by an out-
of-network provider on February 22, 2023. 
  
You asked the Plan to pay more for the dental service. You say that you are appealing the denied anesthesia 
and the amount paid for the biopsy. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The total amount billed for the biopsy of oral tissue was $350 and the total allowed amount was $109 leaving a 
difference of $241 ($350 billed - $109 allowed). You have been asked to pay the difference between the out-of-
network provider's charges and the Plan's payment. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for the 
biopsy of oral tissue (D7286) provided by an out-of-network provider on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and 
the sport back interface (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and sport back interface. You say that these items 
are medically necessary for the enrollee. The Plan denied your request. The Plan says the upgraded electronics 
are not medically necessary. The Plan also says that the mounting hardware is included with the back cushion. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics and sport back 
interface. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has adequate upper body strength to 
manage the standard power drive controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. The requested sport back interface 
is unbundled and cannot be billed separately. The mounting hardware is included with the approved back 
cushion. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics (E2311, 
E2313, E2377) and the sport back interface (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documents support the claim. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken.  
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on October 27, 2022.