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

 
We decided that the Plan does not have to pre-approve 9 months continued use of home ventilator, any type, 
used with non-invasive interface (E0466).  
 
You asked the Plan to pre-approve a ventilator. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says under Medicare, the request for continued use 
of non-invasive ventilator (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 a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found continuation of the home ventilator is not medically necessary. This enrollee has COPD and 
obstructive sleep apnea and has had a home ventilator since February 2022. There is no documentation that 
BiPAP with average volume assured pressure support (AVAPS) has been tried and failed as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. The current 
device has been approved for 3 months which allows time to transition to BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months continued use of home ventilator, any type, used with non-invasive interface 
(E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drugs (D9612) provided on 
February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan informed you that if the procedures 
were under $2,000, they would be covered. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. 
 
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, 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 the 
therapeutic parenteral drugs (D9612) provided on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pelvic fixation (22848). 
 
You asked the Plan to pre-approve pelvic fixation. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 pelvic fixation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident for the pelvis. Moreover, there are no diagnostic studies 
provided to corroborate pathology for which surgery is being requested. No compelling rationale is 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 pelvic fixation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pelvic fixation (22848).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2023, billed with 
codes 81279, 81321, 81339 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were a medical 
necessity for the enrollee. 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 
February 6, 2023, billed with codes 81279, 81321, 81339 and 81345.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85007 and 85005 billed for date of service 
March 30, 2023.   

You asked the Plan to pay for procedure codes 85007 and 85005. You say that the enrollee was in a nursing 
home and needed medically necessary services. The Plan denied your request. The Plan says payment for code 
85007 is bundled into payment for code 85008 and 85005 is bundled into payment for code 85025. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 85007 
is a column II code to column I code 85008 and 85005 is a column II code to column I code 85025 with a 
modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
85007 and 85005 billed for date of service March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections (D0001) provided on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the treatments and service should be 
covered because they were medically necessary, and they should be covered under an extra-contractual benefit. 
The Plan denied your request. The Plan says a 1-time exception was made for the enrollee to see the provider 
that has opted out of Medicare and the injections are not covered by the Plan. 
 
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, 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 the 
injections (D0001) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state provided on December 19, 
2022.  
 
You asked the Plan to pay for a determination of refractive state. You say that you contacted the Plan regarding 
the amount of this claim and was told that you had not gotten a referral for this provider. You also say that you 
were previously told you did not need a referral. The Plan denied your request. The Plan says eye refractions 
are only covered by your plan if performed by a participating Plan vision provider and performed during a 
routine eye examination. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Medicare-covered services include outpatient 
physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for 
age-related macular degeneration. The Plan contract also says that Original Medicare does not cover routine 
eye examinations (eye refractions) for eyeglasses/contracts. Based on this information, we decided that the 
Plan's rules for coverage of  a determination of refractive state have not been met. Therefore, we decided that 
the Plan does not have to pay for a determination of refractive state provided on December 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Medication assisted treatment, methadone (G2067) take-
home supply of methadone (G2078) provided on February 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the opioid treatment. You say that you are a walk-in clinic not contracted with 
the Plan. A referral, authorization, recertification or notification is not required. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Medication assisted treatment, methadone 
(G2067) take-home supply of methadone (G2078) provided on February 20, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 19, 2022, billed 
with codes 81209, 81223, 81250, 81305, and 81320. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 
December 19, 2022, billed with codes 81209, 81223, 81250, 81305, and 81320.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair expandable controller upgrade, 
harness upgrade, occupied transit, attendant control, calf pad, and electronic connection between wheelchair 
controller and two or more power seating system motors. 
 
You asked the Plan to pre-approve power wheelchair expandable controller upgrade, harness upgrade, occupied 
transit, attendant control, calf pad, and electronic connection between wheelchair controller and two or more 
power seating system motors. You say that your doctor feels the tilt on the wheelchair is medically necessary. 
The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. 
Although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. The enrollees upper limb strength and function are 
adequate for the enrollee to be able to control the power options using their own switches which are included in 
the allowance of these power options. This means the requested electronic connection, expandable controller, 
and harness are not covered. If an attendant control is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered. This means the requested attendant control is not covered. The 
requested transit option at issue in this appeal is for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. The requested calf pad is a 
replacement code and cannot be covered on initial issue. In addition, calf pads are unbundled from the power 
wheelchair base and cannot be requested separately. 
 
Based on this information, we decided that Medicare rules for coverage of power wheelchair expandable 
controller upgrade, harness upgrade, occupied transit, attendant control, calf rest pad, and electronic connection 
between wheelchair controller and two or more power seating system motors have not been met. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair expandable controller upgrade, harness 
upgrade, occupied transit, attendant control, calf pad, and electronic connection between wheelchair controller 
and two or more power seating system motors.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87529 billed for date of service February 21, 2023. 
 
You asked the Plan to pay for procedure code 87529. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this code is not supported in 
the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 87529 is infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified 
probe technique. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87529. Our reviewer says that this code is 
supported in the documentation provided. Our reviewer found the laboratory report includes a negative result 
for Herpes simplex virus, and therefore this service should be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87529 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87529 billed for date of service February 21, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from  
January 27, 2023, through January 28, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the medications provided are not covered as a 
medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from January 27, 2023, through January 28, 2023.  
 
Benefits for the self-administered drugs provided may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the moderate sedation. 
 
You asked the Plan to pre-approve the moderate sedation. The Plan denied your request. The Plan says the 
moderate sedation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that that use of moderate or deep sedation, general 
anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for sacroiliac joint 
(SIJ) injections and therefore not considered medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation have not been met. Specifically, the use of moderate sedation with sacroiliac 
joint injections is not considered medically necessary. Therefore, we decided that the Plan does not have to pre-
approve a sacroiliac joint injection with moderate sedation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report provided on March 
8, 2022, and billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81335, 81328, 81355, 81401, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report . You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response Report  have not been met. Therefore, we decided that the Plan does not have to pay for the GeneDose Genetic 
Response Report provided on March 8, 2022, and billed with codes 81225, 81226, 81227, 81230, 81231, 
81232, 81240, 81241, 81291, 81306, 81335, 81328, 81355, 81401, 0031U, 0032U, and 0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 30, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 30, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical correction of hallux rigidus. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show that any conservative interventions have been tried. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation clinically supports that the enrollee is suffering from a painful first 
metatarsal phalangeal joint (MPJ) with limited MPJ range of motion. Positive crepitus and tenderness are noted 
upon first MPJ range of motion right side. Surgical intervention including repair of hallux rigidus/osteoarthritis 
meets the above-mentioned guidelines. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve surgical correction of hallux rigidus.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.