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

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513).  
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service March 6, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641 and 87653. You say that these services are 
supported as billed. The Plan denied your request. The Plan says these services are not supported for separate 
payment. 
 
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 87150, 87481, 87641 and 87653 is a column II code to column I code 
87500 and 87801; however, 87150, 87481, 87641 and 87653 was billed with a modifier.  
 
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 codes 87150, 87481, 87641 and 87653. Our 
reviewer says that these codes are not supported for separate reporting/payment. Our reviewer found the 
laboratory report does not include documentation to support that these were unusual non-overlapping services. 
Therefore, these procedures would be inclusive to CPT codes 87500 and 87801. 
 
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 codes 87150, 87481, 87641 and 87653 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on November 2, 2022. 
  
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on November 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty 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 not medically necessary. Our physician reviewer found there is no documentation on imaging 
studies or in the records that the enrollee's fracture is acute and less than 12 weeks old. The criteria for 
coverage are not met and the kyphoplasty is not reasonable or medically necessary at this time. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7310 x3, D7311). 
 
You asked the Plan to pre-approve alveoloplasty. You say that these services are necessary. The Plan denied 
your request. The Plan says alveoloplasty is not a covered benefit. 
 
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 
alveoloplasty (D7310 x3, D7311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seventy-two (72) office visits (97012, 97110, 98941) 
with a chiropractor to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee must use network providers to get 
medical care and services when there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The 
Plan approved 3 visits to allow the enrollee to obtain an in-network provider. Based on this information, we 
decided that Medicare rules for coverage of office visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seventy-two (72) office visits (97012, 97110, 98941) with a chiropractor to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain. The Plan 
denied your request. The Plan says the enrollee has multilevel disc disease.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for degenerative scoliosis in adult patient, lumbar stenosis 
without neurogenic claudication, and L1 superior endplate vertebral compression fracture. The exam reveals 
tenderness of the upper lumbar spine around L1 and L2. Strength and sensation are intact. However, detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25 percent vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Her past medical history does not corroborate osteoporosis. Moreover, there is magnetic resonance 
imaging corroborating plausible other causes of low back pain. Therefore, the requested kyphoplasty at L1 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87798) provided on March 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (87798) provided on March 29, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (80307) provided on January 13, 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 80307 is "Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by 
instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service". 
 
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 80307 is 
supported by the records provided. Our reviewer found that the laboratory report includes documentation of 
presumptive drug testing, with results expressed as negative or positive or as a numerical result. 
 
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 drug testing services (80307) provided on January 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T7 Kyphoplasty with anesthesia (22513 and 01941). 
 
You asked the Plan to pre-approve T7 Kyphoplasty with anesthesia (22513 and 01941). You say that the 
requested kyphoplasty is medically necessary.  The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested kyphoplasty.  
 
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 T7 Kyphoplasty with anesthesia (22513 
and 01941). Our reviewer says that the enrollee does not meet criteria for the requested kyphoplasty.  Our 
physician reviewer found the enrollee was being treated for age-related osteoporosis with current pathological 
fracture. She presented with chronic low back pain and joint pain and severe mid back pain and chest pressure. 
The low back pain radiates to the lower extremities. The exam reveals tenderness at the T7 spinous process. 
There is paraspinal tenderness at the T6-7 and T7-8. Facet loading is positive bilaterally. The range of motion 
is painful. 
 
However, detailed documentation is not evident regarding worsening pain. There is no indication of a 
progression of the body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there 
is MRI corroboration of other plausible causes of pain. Therefore, the enrollee does not meet the LCD criteria 
for the requested kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T7 Kyphoplasty with anesthesia (22513 and 01941) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve T7 Kyphoplasty with anesthesia (22513 and 
01941).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on October 27, 
2022, by an OON provider.  
 
You asked the Plan to pay for a compression device. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 a pneumatic compression device provided on 
October 27, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220/D0230) provided on March 20, 
2023. 
 
You asked the Plan to pay for periapical x-rays. You say that you needed all of this dental work. The Plan 
denied your request. The Plan says the denied x-rays are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periapical 
x-rays (D0220/D0230) provided on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), 
polycarbonate lenses (V2784), progressive lenses (V2781), and a deluxe lens feature (V2702) provided on 
January 31, 2023. 
 
You asked the Plan to pay for frames (V2020), anti-reflective coating (V2750), polycarbonate lenses (V2784), 
progressive lenses (V2781), and a deluxe lens feature (V2702). You say that the provider overcharged the Plan 
by double. The Plan denied your request. The Plan says this benefit was exhausted with this service. 
 
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 up to $200 for eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that this plan covers up to $200 for eyeglasses or 
contact lenses every year. The Plan rules also says that after the plan pays the benefits for eyeglasses (lenses 
and frames) or contact lenses, the enrollee is responsible for the remaining cost. The record shows that the Plan 
paid $23225, which is more than the allowed allotment to the provider. Based on this information, we decided 
that the Plan's rules for coverage of frames (V2020), anti-reflective coating (V2750), polycarbonate lenses 
(V2784), progressive lenses (V2781), and a deluxe lens feature (V2702) have not been met. Therefore, we 
decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), polycarbonate 
lenses (V2784), progressive lenses (V2781), and a deluxe lens feature (V2702) provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT scan provided on May 31, 2023. 
 
You asked the Plan to pay for a cone beam CT scan. You say that you had an exposed root and an infection. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam CT scan provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on April 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to reimburse you for the 
denied dental service. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the consultation 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on April 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that due to the 
enrollee's medical and stroke related history the call to the paramedics was medically necessary. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 2, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) for tooth #14 
provided on April 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that the procedures are different procedures done at 2 
different times so the dental services should be covered. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a custom fabricated abutment (D6056) for tooth #14 on April 11, 2023; therefore, your 
benefit for the custom fabricated abutment (D6057) was exhausted on the date of service of April 11, 2023. 
Therefore, we decided that the Plan does not have to pay for a custom fabricated abutment (D6057) for tooth 
#14 provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), a 2D photographic 
image (D0350), and a 3D dental surface scan (D0801) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that a pre-authorization was 
required for the dental services. 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 Plans 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 a 2D photographic image (D0350) on April 17, 2023; therefore, your benefit for the 2D 
photographic image and a 3D dental surface scan was exhausted on the date of service of April 17, 2023. The 
record also shows that the Plan paid for intraoral complete series of radiographic images (D0210) on March 3, 
2021; therefore, your benefit for the panoramic radiographic image was exhausted n the date of service of 
March 3, 2021. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image 
(D0330), a 2D photographic image (D0350), and a 3D dental surface scan (D0801) provided on April 17, 2023.