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

 
We decided that the Plan does not have to pre-approve a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that a power wheelchair is recommended to 
provide mobility for activities of daily living in the home due to the enrollee's CVA. You also say the enrollee 
meets criteria for the requested accessories. The Plan denied your request. The Plan says the notes state that 
these are needed when 3 or more actuators are being used. The Plan also says the enrollee does not meet 
criteria for the requested harness and expandable controller. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that although there are three requested power options, there is not a medical need to control 
these options through the joystick. The records show that the enrollee has 3/5 strength in the right upper 
extremity and independent with feedings. The enrollee can control the power options included in the allowance 
of these power options. This means that Medicare rules for coverage of PMD accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a harness (E2313) and an expandable 
controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve an ultralightweight manual wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member is not a full-time manual wheelchair user 
and already has an item that serves the same purpose. 
 
The Plan must follow Medicare rules. The rules say the beneficiary must be a full-time manual wheelchair user 
for an ultralightweight manual wheelchair and Medicare will not cover equipment that serves the same purpose 
as usable equipment previously purchased for the member. 
 
The file shows that the enrollee has a power wheelchair. A power wheelchair serves the same purpose as an 
ultralightweight manual wheelchair and means that the enrollee is not a full-time manual wheelchair user. 
Therefore, we decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair 
(K0005).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all quadrants. 
 
You asked the Plan to pre-approve gingival irrigation (D4921) for all quadrants. You say that you wish to do 
the gingival procedure for your gums because it really hurt you. The Plan denied your request. The Plan says 
this service is not covered under your benefit plan per the EOC. 
 
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 pre-approve 
gingival irrigation (D4921) for all quadrants.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that you need a home health aide for daily 
living skills. The Plan denied your request. The Plan says this service is not a covered benefit under your plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service October 6, 2021. Specifically, the 
Plan provides coverage of this dental item once every 60 months. You previously received this item on  
October 6, 2021, which was paid for by the Plan. Therefore, the allowable benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #29 and 31 (D2950), a pontic on 
tooth #30 (D6241), and crowns on tooth #29 and 31 (D6751). 
 
You asked the Plan to pre-approve the dental services. You say that you are asking the Plan to reconsider 
coverage for these services. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by the enrollees supplemental 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. 
 
The Plan confirmed your out-of-network at the requested service address. 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 from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve 
core build up on tooth #29 and 31 (D2950), a pontic on tooth #30 (D6241), and crowns on tooth #29 and 31 
(D6751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 12) and bone grafting (D7953). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the extractions, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 12) and bone grafting (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
one power seating system motor and repair or non-routine service for durable medical equipment other than 
oxygen equipment requiring the skill of a technician, labor component. 
 
You asked the Plan to pre-approve electronic connection between wheelchair controller and one power seating 
system motor and Repair or non-routine service for durable medical equipment other than oxygen equipment 
requiring the skill of a technician, labor component. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that while one power feature is requested on 
this wheelchair (power tilt), there is not a medical need to control this power option through the joystick. The 
enrollee has upper limb strength of four to five out of five. The enrollee has adequate upper limb strength and 
function to be able to control the power option using its own switch which is included in the allowance of the 
power option. Labor costs are included with the requested power wheelchair and cannot be requested 
separately. Based on this information, we decided that Medicare rules for coverage of electronic connection 
between wheelchair controller and one power seating system motor and Repair or non-routine service for 
durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component 
have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection 
between wheelchair controller and one power seating system motor and repair or non-routine service for 
durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior instrumentation (22845) provided on July 8, 
2022. 
  You asked the Plan to pay for the anterior instrumentation (22845). You say that the documents support the 
procedure, and the claim should be reprocessed for correct payment. The Plan denied your request. The Plan 
says procedure code 22845-59 is not supported by the medical records submitted. 
 
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 22845 is a column II code to column I code 22853; however, 22845 
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 anterior instrumentation (22845). Our reviewer says that 
the documentation does not support 22845 as a separate and distinct procedure. Our reviewer found the 
instrumentation was part of the biomechanical device insertion reported with 22853. The documentation states 
that these interventions were performed at the same levels as part of the same procedure. According to the 
NCCI manual, instrumentation to anchor the device to intervertebral disc space is not separately reportable. 
 
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 anterior instrumentation (22845) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anterior instrumentation (22845) provided on July 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
show to need the inpatient level and intensity of care given in the inpatient rehabilitation setting. The enrollee's 
rehabilitative care may be safely accomplished at the lower level of care where the enrollee is currently 
admitted at a Skilled Nursing Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth #1 and 16 (D7240). 
 
You asked the Plan to pre-approve the tooth removal. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the removal of an impacted tooth (D7240) is not covered 
by 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 pre-approve the 
removal of impacted tooth #1 and 16 (D7240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
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 July 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services at issue have been billed 
correctly. 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 July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external upper limb tremor stimulator of the peripheral 
nerves of the wrist (K1018) provided October 15, 2021. 
 
You asked the Plan to pay for the Cala Trio device stimulator. You say that the enrollee has been using the 
Cala Trio device and seeing improvement and control over their hand essential tremor. The Plan denied your 
request. The Plan says this device is considered experimental and investigational. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cala Trio device stimulator have not been met. Therefore, we decided that the Plan does not 
have to pay for the external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) 
provided October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (E2313) and electronic 
connection between wheelchair controller and two or more power seating system motors, including all related 
electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) 
cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. The 
enrollee is independent in use of current power wheelchair without any specialty controller; no specialty 
controller requested. The enrollee's upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
Medicare Guidance says that upgraded electronics (expandable controller, harness and electronic connector to 
2 power options) are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (E2313) and electronic connection between wheelchair controller and two or more power 
seating system motors, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the claim 
decision on a recent visit for an oral evaluation. 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 August 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on September 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 97598. The Plan denied your request. The Plan says payment for 
code 97598 is bundled into payment for code 11042. 
 
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 97598 
is a column II code to column I code 11042. 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 97598 billed for date of service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair (K0005) 
replacement. 
 
You asked the Plan to pre-approve an ultralightweight manual wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says a replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ultralightweight manual wheelchair have not been met. Specifically, the records show this 
request is being made for age related wear and tear. Replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. Therefore, we decided that the Plan does not have to pre-approve 
an ultralightweight manual wheelchair (K0005) replacement.