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

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental and therefore is not covered. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate is experimental for use as bone graft material in spine surgery. Therefore, the reviewer found that the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cooling caps purchased on April 11, 2023. 
 
You asked the Plan to pay for the cooling caps. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that while ice-filled bags or bandages or other 
devices used for scalp hypothermia during chemotherapy may be covered as supplies of the kind commonly 
furnished without a separate charge, no separate charge for them would be recognized. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cooling caps have not been met. Therefore, we decided that the Plan does not have to pay for 
the cooling caps purchased on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81351) provided on March 27, 2023. 

You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
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. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81351) provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that this is causing the enrollee a lot of pain 
and is interfering with their daily lives. The Plan denied your request. The Plan says this does not meet the 
criteria for coverage. 
 
 
 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 facet joint injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation of cervical 
radiculopathy.  Therefore, the enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on May 19, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider never told you that you would be 
charged for the dental services. The Plan denied your request. The Plan says the denial of payment for the 
extraction is correct, because no tooth number was submitted with the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental service have been met. 
Specifically, the notice of denial of payment was issued on June 17, 2023, stating that you needed to submit the 
required tooth number for the surgical extraction and without a valid tooth number the claim could not be paid. 
Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on May 
19, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005. We decided that the Plan does not have to pay 
for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service April 12, 2023. You say that the 
documentation shows medical necessity. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for procedure code U0005.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, 
making use of high throughput technologies, completed within 2 calendar days from date of specimen 
collection (list separately in addition to either code U0003 or U0004) as described by CMS-2020-01-R2. 
 
In this case, we have confirmed that code U0005 is an add-on code that has been billed with appropriate 
primary procedure code, U0004, which the Plan has agreed to pay. The records show that the testing was 
completed within 2 days from the date the specimen was collected. Based on the claim submitted, Medicare 
billing criteria have been met. Therefore, we decided that the Plan has to pay for procedure code U0005 billed 
for date of service April 12, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 
87532, 87541, 87581, 87640, 87651, and 87798. 
 
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. The provided panel testing was not billed with a single code as 
required. 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 codes 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87640, 87651, and 87798 billed for date of service April 12, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transport services (A0428) billed under 
claim number ending in 3832-00 for date of service April 25, 2023. 
 
You asked the Plan to pay for the non-emergency transport. You say that this should be paid. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the service at issue was reimbursed by 
the Plan on May 31, 2023, under claim number ending in 2038-00. Comparison of the two claims shows these 
are exact duplicates. There is no evidence presented to support that the billed service was provided twice on the same date. Based on this information, we decided that the Medicare rules for the non-emergency transport have 
not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency transport 
services (A0428) billed under claim number ending in 3832-00 for date of service April 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and 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 is multifactorial 
with multilevel disc disease. 
 
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 L1 and L2 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation 
is not evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the 
body height loss, greater than 25% vertebral body height loss at all levels requested, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration of other 
plausible causes of 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 L1 and L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel provided on June 20, 2023, billed with 
codes 87798-90 x12, 87481-90, 87150-90 x12, 87801-90 x3. 
 
You asked the Plan to pay for the laboratory testing billed. You say that kindly review the attached documents 
and process this claim towards possible 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a test 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 laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR panel 
provided on June 20, 2023, billed with codes 87798-90 x12, 87481-90, 87150-90 x12, 87801-90 x3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4267) on tooth 19 billed for 
date of service May 15, 2023. 
 
You asked the Plan to pay for guided tissue regeneration on tooth 19. You say that this should be covered. The 
Plan denied your request. The Plan says this was not billed with an appropriate code. 
 
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 D4267 is guided tissue regeneration, natural teeth  non-
resorbable barrier, per site. This procedure does not include flap entry and closure, or, when indicated, wound 
debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in 
osseous regeneration. This procedure can be used for periodontal defects around natural teeth.. 
 
We find that CPT code D4267 is not supported in the medical record. Specifically, this code is specific to 
natural teeth and the record shows that tooth 19 has been extracted. Based on this information, we decided that 
Medicare rules for coverage of guided tissue regeneration on tooth 19 have not been met. Therefore, we 
decided that the Plan does not have to pay for guided tissue regeneration (D4267) on tooth 19 billed for date of 
service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment codes A5500-LT and A5500-RT 
billed for date of service March 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that  medical records were provided. The Plan 
denied your request. The Plan says the service did not meet the coding regulations. 
 
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 codes A5500-LT and A5500-RT were paid by the Plan for date of service March 6, 2023. These 
codes are payable only once in a calendar year. 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 
durable medical equipment codes A5500-LT and A5500-RT billed for date of service March 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 1, 2023, billed with 19 
units of code 87798. 
 
You asked the Plan to pay for the lab testing as billed. You say that this was medically necessary.  The Plan 
denied your request. The Plan says without a lab report, the billed services cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab testing as billed have been met. 
The documentation submitted did not include a lab report. As such, it cannot be confirmed that 19 units of 
87798 were performed or correctly coded. Therefore, we decided that the Plan does not have to pay for the lab 
testing provided on March 1, 2023, billed with 19 units of code 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the physician service. You say that there are no network providers that are 
accepting new patients. You say that you have been seeing the requested provider since September 2022. You 
also say that you would like to continue with this provider as there are none available in your area. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-
approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81345 provided on May 26, 
2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code 81345 provided on May 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ sacroiliac (SI) joint stabilization system. 
 
You asked the Plan to pre-approve the LinQ SI joint stabilization system. You say that if the procedure is not 
approved, the enrollee will continue to be reliant on expensive conservative treatments and harmful opioids.  
The Plan denied your request. The Plan says the LinQ SI joint stabilization system is not medically necessary. 
The Plan says the evidence-based literature does not support the routine use of the LinQ device over traditional 
treatment.  
 
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 LinQ SI joint stabilization system. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee was being treated for sacroiliitis. The documentation is not evident regarding imaging or radiographic evidence supporting a sacroiliitis pathology. There are multiple other 
possible causes of pain generators at the lumbosacral spine. 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 the LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the LinQ sacroiliac (SI) joint stabilization system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the application of a compression system 
and the debridement procedures provided on December 22, 2022, and December 30, 2022. 
 
You asked the Plan to waive the copayments for the application of a compression system and the debridement 
procedures. You say that you were told that you would not have a cost share for these services. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. 
 
 You have been asked to pay $196.42, which is less than the standard copayment for each debridement 
procedure provided on December 22, 2022, and December 30, 2022. You have also been asked to pay $77.27, 
which is less than the standard copayment for the application of a compression system provided on December 
30, 2022. These items/services fall within the outpatient surgery and other medical services provided at hospital 
outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. 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 waive the copayments for the application of a 
compression system and the debridement procedures provided on December 22, 2022, and December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 30, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that this was an appointment to get your stitches 
out after surgery. You also say that this should be covered under a global period post surgery. The Plan denied 
your request. The Plan says the service was not authorized and therefore is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient service have been met. 
Though the service at issue does fall under the Definition of a Global Surgical Package, there were no medical records provided to support the billed service. The Plan requested records, but none were provided. Therefore, 
we decided that the Plan does not have to pay for the office visit (99213) provided on June 30, 2023.