Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) billed for dates of service December 
7, 2022, to December 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are valid and billable. The Plan denied 
your request. The Plan says the service is excluded from coverage. 
 
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. Infrared therapy is a non-covered treatment. 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 infrared therapy (97026) billed for dates of service December 
7, 2022, to December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T8 and T9 (22513). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when all the criteria listed in 
the Medicare rules section 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 a kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the detailed documentation is not 
evident regarding the compression fractures at T8 and T9 being acute or subacute in nature. The provided 
diagnostic testing did not label them as acute or subacute. The examination noted the enrollee has had pain for 
greater than a year. The pain level is not clearly documented. The progression of vertebral body height loss is 
not clearly documented. Moreover, there are other plausible causes of pain noted in the thoracolumbar spine. 
 
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 at T8 and T9 (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service November 
17, 2022.  

You asked the Plan to pay for procedure code 99221. You say that a corrected claim was submitted. The Plan 
denied your request. The Plan says no modifier is allowed with this code pair. 
 
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 99221 is a column II code to column I code 99223 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99221 
billed for date of service November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 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. 
 
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 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume 
assured pressure support (AVAPS) capability and failure of such a device has not been documented. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one pair of frames (V2020) provided on December 1, 2022. 
 
You asked the Plan to pay for one pair of frames (V2020). You say that you had cataract surgery and needed 
glasses for close up. The Plan denied your request. The Plan says charges for vision care services and supplies 
are excluded from coverage under your plan. 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of eyeglasses or contact lenses 
after each cataract surgery that includes insertion of an intraocular lens. The record shows this benefit has been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of one pair of frames 
(V2020) have not been met. Therefore, we decided that the Plan does not have to pay for one pair of frames 
(V2020) provided on December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (code 87640) provided on January 27, 
2023. 
 
You asked the Plan to pay for the testing. You say that the coding and diagnosis are both approved by 
Medicare, and the Plan is required to pay.  The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 87640 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, amplified probe technique. 
 
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 testing. Our reviewer says that the criteria for coverage 
has not been met. Our reviewer found an NCCI edit exist for CPT 87640 and CPT 87641. Although a modifier 
is allowed to bypass the edit, documentation should support the service as a separate procedure. In this case, the 
laboratory report does not include documentation to support modifier -59 distinct procedural service. 
Therefore, the procedure cannot be verified as distinct from CPT 87641 and has been denied correctly. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing (code 87640) provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 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. 
 
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 a ventilator for 9 months a ventilator for 9 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found provided records 
document that the home ventilator is being requested for use in intelligent volume assured pressure support 
(IVAPS) mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) 
device with average volume assured pressure support (AVAPS) and a back-up rate. 
 
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 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
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 December 12, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641 and 87653. You say that these services 
were reported correctly and are supported in the medical record. The Plan denied your request. The Plan says 
the payment for these codes is included in the payment for other codes reported. The medical records do not 
support that these were separate services. 
 
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 codes 87150, 87481, 87641 and 87653 are column II codes to column I 
codes 87500 and/or 87801. Code 87481 was not billed with an appropriate modifier to bypass the edit. Based 
on the claim submitted, Medicare billing criteria have not been met for code 87481. However, codes 87150, 
87641 and 87653 were each 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, 87641 and 87653. Our reviewer says 
that these services are not supported with the 59 modifier. Our reviewer found although a modifier is allowed 
to bypass an NCCI Edit, documentation should support the service as separate from the primary procedure. In 
this case, the laboratory report does not include documentation to support the appended modifier 59 (distinct 
procedural service) to any of these codes, and therefore cannot be verified. 
 
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 December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (codes 87481 and 87653) provided on 
December 20, 2022.  
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the 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, we have confirmed that code 87481 is a column II code to column I code 87801. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met for code 87481. 
 
We have also confirmed that code 87653 is a column II code to column I code 87801; however, 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 the testing. Our reviewer says that the criteria for coverage 
have not been met. Our reviewer found the medical documentation does not support that the use of procedure 
code 87653 was distinct from procedure code 87801. Procedure code 87801 is inclusive with 87653 and 
procedure code 87653 cannot be verified as separate. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing (codes 87481 and 87653) provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chemodenervation procedure provided 
on December 22, 2022. 
 
You asked the Plan to waive the copayment for the surgery services. You say that you did not have surgery. 
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 $325 
for each Medicare-covered in-network outpatient hospital facility visit.  
 
You have been asked to pay a $270.38, which is less than the standard copayment for the surgery services. This 
item/service falls within the outpatient surgery including 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 copayment for the chemodenervation procedure 
provided on December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles, a seat pouch and side guards for a 
wheelchair. 
 
You asked the Plan to pre-approve push handles, a seat pouch and side guards. You say that the requested items 
are a necessity for your care. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve push handles, a seat pouch and side guards for a wheelchair.
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 February 8, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. 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 February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) for teeth # 2, 3, 4, 5, 6, 
11, 12, 13, 14, 18, 19, 20, 21, 22, 27, 28, 29, 30, and 31. 
 
You asked the Plan to pre-approve surgical extractions. You say that surgical removal of these teeth is 
medically necessary and cannot be downgraded. The Plan denied your request. The Plan says that surgical 
removal of these teeth is not medically necessary; however, these extractions are approved and may be 
provided as standard extractions (D7140). 
 
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. The Plan covers surgical 
extractions when the services are medically necessary and reasonable. 
 
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 surgical extractions. Our reviewer says 
that the documentation provided meets the criteria for coverage for surgical extractions of teeth #'s 2-6,11-
14,18-22 and 27-31. Our physician reviewer found the records indicate that the coronal structures of these teeth 
are severely compromised making standard extractions impossible. Alveoloplasty has been approved for each 
quadrant. Since the alveoloplasty requires a flap procedure and bone remodeling, the surgical extractions are 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical extractions have been met. Therefore, we decided that the Plan has to 
pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210) for teeth # 2, 3, 4, 5, 6, 11, 12, 13, 14, 18, 19, 20, 21, 22, 
27, 28, 29, 30, and 31.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 and 87653 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure code 87481 and 87653. The Plan denied your request. The Plan says 
payment for code 87481 and 87653 is bundled into payment for code 87801. 
 
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 87481 and 87653 is a column II code to column I code 87801. The 
codes at issue have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 87481 and 87653 billed for date of service November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, K0108, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
provided records do not support that the enrollee is high risk for skin breakdown (mild risk on Braden scale), 
has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs 
bladder self-catheterization and is unable to transfer independently or that the enrollee has increased muscle 
tone or spasticity (on a physician's examination) to meet criteria for the power tilt and/or recline and thus the 
multiple power option base as required by the LCD. Provided records document that the enrollee has 3+/5 to 
4/5 right upper extremity strength and is independent with feeding and grooming thus indicating he has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2607, K0108, K0861).