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

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a Cala Trio tremor stimulator device (K1018) and  supplies for use with the device 
(K1019) are not medically necessary per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body enrollee. There is 
insufficient evidence in the literature that this device is effective for the enrollee. The requested K1018 (and 
K019) are not the standard of care for this enrollee's tremor according to current 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 a Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for procedure code 99153. You say that medical records were provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The claim shows the service at issue was provided in an outpatient hospital facility. There is no separate 
payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided 
that the Plan does not have to pay for procedure code 99153 billed for date of service March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve the Cala trio therapy system. You say that you are requesting 
reconsideration because there is compelling clinical evidence supporting the effectiveness and medical 
necessity of the Cala therapeutic device. The Plan denied your request. The Plan says the request is not 
medically necessary because based on the medical literature, this device is considered experimental or 
investigational and has not been proven to be beneficial for the control of tremors. 
 
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 Cala trio therapy system. Our 
reviewer says that the requested item/service does not meet criteria in this case. Our physician reviewer found a 
Cala Trio tremor stimulator device is not medically necessary per the Social Security Act, Section 1862 (a)1(A) 
and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
enrollee. There is insufficient evidence in the literature that this device is effective for the enrollee's tremor. 
The requested K1018 is not the standard of care for this enrollee's tremor according to current 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 Cala trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a necessity for your care. The 
Plan denied your request. The Plan says a kyphoplasty 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 a kyphoplasty. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no imaging in the case record that shows that the fracture is less than 12 weeks old. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator for the 
treatment of obesity hypoventilation syndrome, or when used at settings that can be provided with 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 a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (25605) provided on March 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 25605 is "Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, 
includes closed treatment of fracture of ulnar styloid, when performed; with manipulation". 
 
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 the services. Our reviewer says that the use of code 25605 is 
not supported by the records provided. Our reviewer found that the provider documents "Long arm posterior 
splint was removed today in office.  A short arm cast was applied and fracture was reduced in appropriate 
alignment and positioning.  Closed treatment was performed today in office to the left distal radius fracture to 
reduce fracture and allow for healing". In this case documentation describes that the fracture was reduced, and 
short arm cast was applied. 
 
We looked at this coder'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 pay for 
the services (25605) provided on March 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 23, 2023, billed 
with procedure codes 99153 and 92941-RC. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support code 92941-RC, 
and code 99153 is not payable in the facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the OPPS recognizes 
that CPT code 99153 is a PE only code and that PE are not payable to the physician for services provided in the 
facility setting.  
 
In this case, the CPT Code Manual definition of codes 99153 and 92941-RC is moderate sedation services 
provided by the same physician or other qualified health care professional performing the diagnostic or 
therapeutic service that the sedation supports, requiring the presence of an independent trained observer to 
assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 
minutes intraservice time (List separately in addition to code for primary service), and percutaneous 
transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary 
artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, 
including aspiration thrombectomy when performed, single vessel. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support code 92941-RC. Our reviewer found that the medical record does not include 
documentation to support revascularization of acute total/subtotal occlusion during acute myocardial 
infarction.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. We find that payment for 
CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 
99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on January 23, 2023, billed with procedure codes 99153 and 92941-RC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), a 
custom fabricated abutment (D6057), and the abutment supported to crown (D6058) for tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that the best option for the enrollee is to have 
implants completed. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the Plan paid for the surgical placement of implant body (D6010) for tooth #30 on January 12, 2023, and 
pre-approved the surgical placement of implant body (D6010) for tooth #12 on August 16, 2023; therefore, the 
enrollee's benefit for the surgical placement of implant body (D6010) was exhausted on the date of approval of 
August 16, 2023. On July 7, 2023, the Plan paid for a custom fabricated abutment (D6057) for tooth #30 and 
pre-approved a custom fabricated abutment (D6057) for tooth #12 on July 17, 2023; therefore, the enrollee's 
benefit for the custom fabricated abutment (D6057) was exhausted on the date of approval of July 17, 2023. On 
July 7, 2023, the Plan paid for the abutment supported to crown (D6058) for tooth #30 and pre-approved the 
abutment supported to crown (D6058) for tooth #12 on August 16, 2023; therefore, the enrollee's benefit for 
the abutment supported to crown (D6058) was exhausted on the date of approval of August 16, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010), a custom fabricated abutment (D6057), and the abutment supported to crown (D6058) for tooth #13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on February 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded". 
 
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 the services. Our reviewer says that the use of code 99223 is not supported by the records provided. Our reviewer found that the records did not support a high level of 
medical decision-making or evidence of an encounter of more than 75 minutes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223) provided on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this procedure 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause of the enrollee's back 
pain. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or necessary. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator for 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found a home ventilator is not 
medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average 
volume assured pressure support (AVAPS) during sleep as an outpatient. The records state that BiPAP with 
AVAPS has failed, but there is no documentation that this 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. Alarms and battery 
backup are not medically necessary. 
 
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 for 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk foot described by code L5981. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a flex-walk foot (L5981) is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee had a left transtibial 
amputation in September of 2022 after infection following a leg fracture. He has resumed ambulation using a 
preparatory prosthesis, but given normal residual limb maturation, the socket is now ill fitting. The submitted 
records support that he meets the criteria for a K3 ambulator. He lives independently at home and goes out in 
the community without limitation, including caring for his yard, hunting, fishing, and he plans to resume work 
in construction. The services are therefore reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a flex-walk foot described by code L5981.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0011 billed for date of service January 8, 
2023. 
 
You asked the Plan to pay for procedure code H0011. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 H0011 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0011 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0011 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0011 billed for date of service January 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional trips are 
necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.