Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary as the records do not show acute or subacute 
vertebral compression fracture, since the fracture is greater than 12 weeks old. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding an acute or subacute fracture at the T12 level. There is no indication of a progression of 
the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging corroboration of posterior-superior border of 
the T12 vertebral body protrudes 7 millimeters into the spinal canal, deforming of the adjacent spinal cord and 
with moderate-severe spinal canal narrowing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the glutathione (J3490), sodium chloride (J3490), 
cooled priority shipping (A9270) provided on February 9, 2023. 
 
You asked the Plan to reimburse you for the glutathione, sodium chloride, and shipping. You say that that this 
provider is in-network. You say that this IV treatment is self-administered by yourself. You also say that you 
are a shut-in due to your illness and cannot go to a doctor's office for treatment. The Plan denied your request. 
The Plan says these services are non-covered by Medicare and the Plan. 
 
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 A9270 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code A9270 is non-covered. Based on this information, we decided that Medicare rules for coverage 
of A9270 have not been met. Additionally, procedure code J3490 has a status indicator of E on the Physician 
Fee Schedule. This means that procedure code J3490 is not payable either. Therefore, we decided that the Plan 
does not have to reimburse you for the glutathione (J3490), sodium chloride (J3490), cooled priority shipping 
(A9270) provided on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 Ossur Pro-Flex foot coded with L5986 and L5987 for the enrollee.
You asked the Plan to pre-approve a K3 Ossur Pro-Flex foot. You say that the enrollee qualifies for the requested foot because of his K3 activities and desire to continue with his active lifestyle. The Plan denied your request. The Plan says that the incorrect codes are being requested for coverage of a K3 Ossur Pro-Flex foot.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a K3 Ossur Pro-Flex foot. Our Medical Director states that the L5987 and L5986 do not match the prosthesis "Ossur Pro-Flex XC". The Pro-Flex XC would correctly be coded L5981, and the Pro-Flex XC Torsion would correctly be coded L5987 and L5984. Neither of these is consistent with the requested codes. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a K3 Ossur Pro-Flex foot.
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 K3 Ossur Pro-Flex foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 Ossur Pro-Flex foot coded with L5986 and L5987 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services for date of service June 22, 2022, to July 21, 2022.

You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.

In this case, the start of care date is June 22, 2022. The NOA was not received by the Plan. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for date of service June 22, 2022, to July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the aluminum rigid removable Std side guards (K0108) 
 
You asked the Plan to pre-approve the side guards. You say that you request a formal mixed decision to 
independently review these items and issue a formal determination in order to pursue other funding resources 
for these items.  The Plan denied your request. The Plan says the side guards, is a convenience item and 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 looked at the file, and Medicare rules. The side guards do not serve a medical purpose, is a convenience 
item and is no covered. Based on this information, we decided that Medicare rules for coverage of the side 
guards have not been met. Therefore, we decided that the Plan does not have to pre-approve the aluminum rigid 
removable Std side guards (K0108)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0781-RR-KX billed for date of service 
March 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the supplies were medically necessary. The Plan 
denied your request. The Plan says an appropriate modifier was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code E0781-RR-KX was not billed with a modifier indicating which month of rental the 
claim was billed for. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
E0781-RR-KX billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit tie downs (K0108 x2) and replacement calf pads 
(E0995 x2). 
 
 You asked the Plan to pre-approve the transit tie downs and replacement calf pads. You say that it is medically 
and functionally necessary for the enrollee to have a power wheelchair with power tilt to address their in-home 
needs. You also say that the enrollee s capable and willing to operate he power wheelchair within their home 
environment. The Plan denied your request. The Plan says transit tie downs are for use outside of the home and 
do not serve a medical purpose. The Plan also says the request for replacement calf pads (E0995) is included in 
the base allowance for the K0838 power wheelchair. 
 
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. Medicare rules also say that a replacement calf pad is included in the 
allowance for the group 2 heavy duty power wheelchair (K0838) when provided at the same time. 
 
The transit tie downs at issue in this appeal is for use outside of the home. Although transit tie downs 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 pre-approve transit tie downs (K0108 x2) and replacement calf pads (E0995 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain in multifactorial with 
multilevel disc disease in the lumbar spine and retropulsion at L1 vertebrae. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L2 kyphoplasty. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging corroboration of other plausible causes of her 
back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 95999 and 95861 for date of service June 15, 2022.

You asked the Plan to pay for procedure codes 95999 and 95861. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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 CPT code.

We find that CPT codes 95999 and 95861 are not payable as billed. Specifically, the train-of-four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP), and therefore, code 95999 is not separately payable. Needle electromyography is not a covered benefit for intraoperative testing during spinal surgery. Therefore, code 95861 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes 95999 and 95861 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95999 and 95861 for date of service June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and limited oral evaluation - problem focused (D0140) provided on March 8, 2023, and March 29, 2023. 
 
You asked the Plan to pay for the mandibular partial denture - flexible base, intraoral - periapical first 
radiographic image and limited oral evaluation - problem focused.. You say that D5226 is covered by the 
dental plan and no claim has been made or paid by the plan for a partial denture in the past five years. The Plan 
denied your request. The Plan says your benefit for the intraoral - periapical first radiographic image and 
limited oral evaluation - problem focused 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 intraoral - periapical first radiographic image and limited oral evaluation - problem 
focused was exhausted on date of service January 25, 2023. Therefore, we decided that the Plan does not have 
to pay for the intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem 
focused (D0140) provided on March 8, 2023, and March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health or hospice setting, each 15 minutes (G0151x8). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that the enrollee is mod I with ambulation up to 135 feet and mod I with other mobility 
tasks. The records do not show that the requested additional skilled therapy services would be required in the 
home setting to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice 
setting, each 15 minutes (G0151x8).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injection at the additional levels. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says the facet joint 
injection 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 pay for the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the provider did not provide 
evidence of a unique circumstance for the requested three level procedure. Therefore, the review has 
determined that the enrollee does not meet the LCD criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for facet joint injections at the additional levels.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Depuy Synthes Vivigen allograft (20930). 
 
You asked the Plan to pre-approve the Depuy Synthes Vivigen allograft. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of 
high-quality peer-reviewed medical literature to establish the safety and efficacy of the requested product for 
use in lumbar fusion procedures. 
 
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 Depuy Synthes Vivigen allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Vivigen allograft is experimental in spine surgery. 
 
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 Depuy Synthes Vivigen allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Depuy Synthes Vivigen allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Affix II Plate (22840). 
 
You asked the Plan to pre-approve Nuvasive Affix II Plate. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-
reviewed medical literature to establish the safety and efficacy of the requested product for use in lumbar 
fusion/decompression procedures. 
 
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 Nuvasive Affix II Plate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Food and Drug Administration (FDA) does not support this device as a stand-
alone device. The provided documentation did not support that the provider plans to use this in conjunction 
with another implant/device. Moreover, there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment. 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 Nuvasive Affix II Plate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Nuvasive Affix II Plate (22840).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 and T12 kyphoplasty (22510, 22512). 
 
You asked the Plan to pre-approve L5 and T12 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial 
with multilevel disc disease in the thoraco-lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L5 and T12 kyphoplasty. Our reviewer 
says that you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 and T12 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L5 and T12 kyphoplasty (22510, 22512).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical access to an implant body (D6011) for tooth 
#3 and #4. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the implant to 
be placed for tooth #3 and #4. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the surgical access to an implant body is 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 pre-approve the 
surgical access to an implant body (D6011) for tooth #3 and #4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J3490, J1170, and 99214-25 billed for date 
of service October 10, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
are not supported. 
 
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 J3490 is unclassified drugs. We find that 40 units of code 
J3490 is not supported. The claim does not indicate what specific drug is associated with this code. We are 
unable to confirm 40 units were provided.  
 
The CPT Code Manual definition of code J1170 is hydromorphone, up to 4 milligrams (mg). The claim shows 
that 96 units were billed. The medical records do not support 96 units of this billed code. Based on this 
information, we decided that Medicare rules for coverage have not been met. 
 
We find that CPT code 99214, billed with the -25 modifier is not supported. The billed modifier is billed for 
visits on the same day as a minor surgery or endoscopy procedure. Code 62370 does not have a global surgery 
indicator. The modifier has not been appropriately appended. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes J3490, J1170, and 99214-25 billed for date of service October 10, 2022.