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

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve the surgery. You say that the records provided support the need for the 
requested services. The Plan denied your request. The Plan says other causes of pain have not been ruled out 
using imaging studies and there is no evidence that the enrollee is being treated for osteoporosis. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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. Additionally, there is magnetic resonance imaging (MRI) corroboration of 
other plausible causes of back pain. Moreover, there is no clear documentation of osteoporosis and/or treatment 
for osteoporosis. Therefore, the criteria for coverage have not been met. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87186 (9 units) and 87088 (3 units) billed 
for date of service September 28, 2022. 
 
You asked the Plan to pay for the services. You say that these services were necessary and reasonable. The 
Plan denied your request. The Plan says these codes are not supported for the number of units billed. 
 
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 the denied codes is: 
 
Current Procedural Terminology (CPT) 87186 (9 units) Susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate  

Current Procedural Terminology (CPT) 87088 (3 units) Culture, bacterial; with isolation and presumptive 
identification of each isolate, urine 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 87186, the 
provider reported 9 units of service, however, laboratory lists 8 antibiotic sensitivity testing. (Ampicillin; 
Cefazolin; Ciprofloxacin; Gentamicin; Ceftriaxone; Nitrofurantoin; Trimethoprim-sulfamethoxazole; 
Amoxicillin/Clavulanic Acid) Therefore, the 9 units billed cannot be verified. 
 
In terms of CPT 87088, the laboratory report does not include sufficient documentation to confirm 3 units 
billed for, culture, bacterial; with isolation and presumptive identification of each isolate.  
 
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 procedure codes 87186 (9 units) and 87088 (3 units) billed for date of service September 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on April 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 your benefit for the requested item or service was exhausted on date of service January 16, 2023. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary denture relining (D5750) provided on April 24, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 your benefit for the requested item or service was exhausted on date of service March 27, 2023. 
Therefore, we decided that the Plan does not have to pay for a maxillary denture relining (D5750) provided on 
April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services outside of the United States (U.S.) from 
February 8, 2022, to September 7, 2022.   

You asked the Plan to pay for the dental services. You say that the EOC does not state you cannot go out of the 
country, so you want reimbursed $1,000. The Plan denied your request. The Plan says you plan does not cover 
care performed outside of the U.S. unless it is an emergency.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. However, Medicare rules state that there is no coverage outside of the United States unless 
there is an emergency. 
 
The record shows you received the requested dental services outside of the U.S. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received outside the U.S. Therefore, we decided that the Plan does not have to pay for dental 
services outside of the United States (U.S.) from February 8, 2022, to September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment supplies billed for date of 
service October 26, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the supplies are 
not covered for low back pain. 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. We find that a TENS unit and related supplies are not covered for 
the treatment of chronic low back pain. 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 the 
durable medical equipment supplies billed for date of service October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 kyphoplasty (22514).  

You asked the Plan to pre-approve L5 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 L5 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding 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 (MRI) 
corroboration of plausible other causes of lower back pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L5 kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (K0856, E1028, E0955, E2361, E1002, E2607 and E1028). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. 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 power mobility devices are 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 and accessories. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a neurologic disorder 
with functional deficits. The documentation does not indicate that the enrollee has any pressure injuries or 
requires intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or 
recline. Although the enrollees condition may meet criteria for a power wheelchair, the criteria for this 
specifically requested power wheelchair with multiple power options including power tilt and recline are not 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of and accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with single power option and accessories (K0856, E1028, 
E0955, E2361, E1002, E2607 and E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer (D2962) provided on February 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a labial 
veneer (D2962) provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply items A4556, A4557, and A4630 billed for date of 
service November 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that the supplies are essential for the use o the TENS 
unit.  The Plan denied your request. The Plan says the supplies are included in the rental allowance. 
 
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 A4556, A4557, and A4630 are not supported. Code A4557 is not reasonable and 
necessary more than once every 12 months. Codes A4556 and A4630 are not valid for claim submission. 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 supply items A4556, A4557, and A4630 billed for 
date of service November 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for closed treatment of radial head or neck fracture; without manipulation 
rendered on April 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that records do not support the services billed. 
 
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 24650 is "Closed treatment of radial head or neck fracture; without 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 services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was being treated for 
non-displaced fracture of head of the left radius, initial encounter for closed fracture; pain in the left elbow; 
effusion of the left elbow. He presented to the emergency department after he struck his left elbow 2 weeks ago 
and has had mild pain since. Overnight, he had significantly increased pain and swelling of the left elbow. He 
is unable to bend the left elbow as this significantly exacerbates his pain. He is a current every day smoker. The 
exam reveals severely limited range of motion of left elbow secondary to pain. There is left elbow edema with 
tenderness to posterior upper arm and joint line. The left elbow x-ray demonstrates a nondisplaced fracture of 
the radial head with moderate joint effusion. At 12:10 a long arm adult splint was applied to the left elbow. He 
was also provided with a sling. Therefore, the records do support that CPT 24650: closed treatment of radial 
head or neck fracture; without manipulation was rendered in this case. 
 
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 
closed treatment of radial head or neck fracture; without manipulation rendered on April 14, 2022.  
 
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 chiropractic services provided on February 7, 2023. to March 21, 2023.

You asked the Plan to pay for chiropractic services. You say that it is medically necessary. The Plan denied your request. The Plan says all services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic.

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 chiropractic services provided on February 7, 2023. to March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral comprehensive series of radiographic images 
(D0210) provided on April 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had to go to a new dentist and they needed 
current x-rays in order to give you a thorough oral exam. 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 the intraoral comprehensive series of radiographic images (D0210) on January 27, 
2022; therefore, your benefit for the requested item or service was exhausted on the date of service of January 
27, 2022. Therefore, we decided that the Plan does not have to pay for the intraoral comprehensive series of 
radiographic images (D0210) provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you have not been able to check your blood sugar 
for weeks. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the medical records do not show that 
the enrollee is insulin treated or has a history of problematic hypoglycemia and documentation of at least 1 or 
more of the following: recurrent (more than 1) level 2 hypoglycemic event [glucose <54mg/dL (3.0mmol/L)] 
that persist despite multiple (more than 1) attempts to adjust medication(s) and/or modify diabetes treatment 
plan or history of 1 level 3 hypoglycemic event [glucose <54mg/dL (3.0mmol/L)] characterized by altered 
mental and/or physical state requiring third-party assistance for treatment of hypoglycemia. The requested 
CGM is not prescribed in accordance with its FDA indications for use. The documentation provided does not 
support that within 6 months prior to ordering the CGM, the treating physician had an in-person or Medicare-
approved telehealth visit with the enrollee to evaluate their diabetes control and determine whether criteria for 
coverage are met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on April 8, 2023. 
 
You asked the Plan to pay for a chiropractic office visit. You say that you do not understand how chiropractic 
treatment can take place if the first visit is not covered. The Plan denied your request. The Plan says this is not 
a covered chiropractic service. 
 
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 an office visit provided by a chiropractor on April 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment billed for date of service 
October 5, 2022. 
 
You asked the Plan to pre-approve the billed services. You say that the items are essential for use of the TENS 
unit. The Plan denied your request. The Plan says the items are not covered for chronic low back pain. 

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 records provided shows that the services were provided to treat 
chronic low back pain. 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 pre-approve durable medical 
equipment billed for date of service October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance routine disposable supplies, coded A0398, billed 
for date of service March 6, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that medical records were provided. The Plan 
denied your request. The Plan says the supplies are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance routine disposable supplies, coded A0398, billed 
for date of service March 6, 2023.