Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup procedure (D2950) prior to replacing a 
crown. 
 
You asked the Plan to pre-approve a core buildup. You say that the requested procedure is required to place the 
new crown. The Plan denied your request. The Plan says the requested procedure is not a Plan 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 pre-approve a 
core buildup procedure (D2950) prior to replacing a crown.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 
provided on July 24, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed and approved for payment based on the medical documentation. The Plan denied your request. The 
Plan says the documentation does not support the services as 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
  
 
The CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician 
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in 
addition to code for primary service). 
 
We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, the 
documentation does not include any evidence of an independent trained observer being present when the 
services were provided. Based on this information, we decided that Medicare rules for coverage of the 
moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the 
moderate sedation services coded 99152 and 99153 provided on July 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance provided on October 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that this fluoroscopic procedure was performed as 
a separate service. The Plan denied your request. The Plan says the code was billed without an appropriate 
primary code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
 We find that CPT code 77003 is not supported. The claim does not show that the code at issue was billed with a 
primary procedure suitable for payment. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the fluoroscopic guidance provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, 
expandable controller harness and a power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve an expandable controller, electronic connection, expandable controller 
harness and a power seat elevation feature. You say that these items are medically necessary. The Plan denied your request. The Plan says that 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 Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature. 
 
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 an expandable controller, electronic 
connection, expandable controller harness and a power seat elevation feature. Our reviewer says that an 
expandable controller, electronic connection and expandable controller harness are not considered medically 
reasonable and necessary in this case. The requested accessories are not medically necessary as the enrollee 
does have use of his hand/upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of an expandable controller, electronic connection, expandable controller harness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, electronic connection, expandable controller harness 
and a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller, electronic connection, expandable controller harness and a power seat 
elevation feature for the enrollee.
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. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee could receive care in another setting. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for exacerbation of chronic obstruction pulmonary disease, congestive heart failure, and chronic 
respiratory failure. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services coded 26440 and 25320 provided on 
March 26, 2021. 
 
You asked the Plan to pay for the surgery services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the documentation does not support 
payment for the CPT codes that were 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 26440 is tenolysis, flexor tendon; palm OR finger, each 
tendon. The CPT Code Manual definition of code 25320 is capsulorrhaphy or reconstruction, wrist, open (eg, 
capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open 
reduction) for carpal instability. 
 
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 surgery services. Our reviewer says that the 
documentation does not support the services as they were billed. Our reviewer found regarding CPT 26440, the 
operative report does describe removal of scar tissue from tendon. That being said, the 4 units that have been 
billed cannot be verified. This procedure is billed incorrectly. Regarding CPT 25320, the operative report does 
not include documentation of joint capsule repair, and therefore this procedure code cannot be verified. 
Operative report describes closure after excision of Volar wrist ganglion, which would be inclusive to the 
excision of ganglion procedure. 
 
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 surgery services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgery services coded 26440 and 25320 provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular testing services provided on August 22, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the billed 
charges. The Plan denied your request. The Plan says the place of service code is not applicable. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim at issue was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the cardiovascular testing services provided on August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem 
focused (D0140), intraoral - periapical first radiographic image (D0220), and endodontic therapy, premolar 
tooth (excluding final restoration) (D3320) provided November 22, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to provide additional payment for the limited oral exam, periapical x-ray and root canal. 
You say that you would not have had the services done if you knew you would be responsible for more than 
you were quoted for. The Plan denied your request. The Plan says these services have been paid according to 
your OON 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 covers the limited 
oral exam, periapical x-ray and root canal with 45% coinsurance when provided OON. You may be responsible for the difference between the Plans allowed amount and the total cost billed by the OON provider. 
 
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that you have 
been asked to pay less than or equal to the correct amount for the OON services.  Therefore, we decided that 
the Plan does not have to provide additional payment for the limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220), and endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) provided November 22, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic cystourethroscopy with ureteroscopy with 
insertion of indwelling ureteral stent provided on July 7, 2021, billed with codes 52531 and 52332. 
 
You asked the Plan to pay for the urological services as billed. You say that the records should support that 
services were medically necessary. The Plan denied your request. The Plan says no operative note was 
submitted for review. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the urological services as billed have 
been met. Though a progress note detailing the planned procedure was submitted, no operative note detailing 
the services rendered was included. An operative/procedure note is necessary to support that payment is due for 
these services. Therefore, we decided that the Plan does not have to pay for the diagnostic cystourethroscopy 
with ureteroscopy with insertion of indwelling ureteral stent provided on July 7, 2021, billed with codes 52531 
and 52332.
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. You say that the enrollee needs the acute rehabilitation to achieve 
his full functional capacity. The Plan denied your request. The Plan says the Inpatient Rehabilitation Facility 
(IRF) services you are requesting do not meet the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you 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 pay for the 7 two dimensional (2D) oral/facial photographic images 
(D0350 x7) provided on December 4, 2020. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that it only makes sense that a 
dentist would need new x-rays if you are becoming a new patient of theirs. The Plan denied your request. The 
Plan says this service is not a covered benefit under your dental plan. The Plan also says that your plan offers a 
dental rider, but you did not enroll in this rider. 
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 pay for the 7 two 
dimensional (2D) oral/facial photographic images (D0350 x7) provided on December 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has tried other medications. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and endodontic therapy (D3330) provided on December 2, 2021. 
 
You asked the Plan to pay for the core buildup and endodontic therapy. You say that you would like $647.00 to 
pay the next dentist to fix your tooth. The Plan denied your request. The Plan says these services are not 
covered expenses under your dental plan. 
 
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 pay for the core 
buildup, including any pins when required (D2950) and endodontic therapy (D3330) provided on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided from October 25, 2021, to October 
28, 2021. 
 
You asked the Plan to pay for the testing services. You say that the enrollee is entitled to a medical screening. 
The Plan denied your request. The Plan says the testing is not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The multiplex PCR respiratory viral panels are effectively a one 
size fits all diagnostic approach, and do not meet Medicares reasonable and necessary criteria. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing provided from October 25, 2021, to October 28, 2021.
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 Inpatient 
Rehabilitation Facility (IRF) services you are requesting do not meet the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you still need medical services for your leg. The 
Plan denied your request. The Plan says that you no longer require daily skilled services and the continuation of 
SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.