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

 
We decided that the Plan does not have to pay for arthroscopy, knee, surgical; synovectomy, limited (eg, plica 
or shelf resection) (separate procedure) provided to the enrollee on July 15, 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 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. 
 
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 the enrollee was being treated for 
unilateral primary osteoarthritis of the left knee. She underwent a left total knee replacement with computer 
navigation and excision of superior synovial mass with extensive synovectomy performed on 7/15/22. 
However, the procedure details a large synovial mass was identified in the superior patellar pouch and this was 
excised as a unit off the superior femoral periosteum...debris and osteophytes in the back of the knee were then 
carefully removed. Once this was done, the trial components were placed and the knee was then taken through 
range of motion. This does not corroborate a limited synovectomy was performed as a separate procedure. Therefore, the records do not support that CPT29875: arthroscopy, knee, surgical, synovectomy, limited (e.g., 
plica or shelf resection) (separate procedure) 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 not been met. Therefore, we decided that the Plan does not 
have to pay for arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate 
procedure) provided to the enrollee on July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis socket replacement (L5301, L5620, L5629, 
L5637, L5645, L5671, L5673, L5910, L5940, L5981, L8420 and L8470). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the requested items are not medically necessary. 
 
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 items. Our physician reviewer 
found the prosthesis socket replacement (L5301, L5620, L5629, L5637, L5645, L5671, L5673, L5910, L5940, 
L5981, L8420, L8470) does not meet medically necessary per LCD: Lower Limb Prostheses (L33787) and per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The requested socket replacement is not 
medically necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The documentation does not reveal an objective gait examination indicating that you 
are a K3 ambulator. The documentation does not support that your needs cannot be safely met with a K2 level 
prosthesis. Per documentation, you were approved for a power wheelchair and have requested repairs. The use 
of a power wheelchair is not consistent with K3 ambulation. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthesis socket replacement (L5301, L5620, L5629, L5637, L5645, L5671, L5673, L5910, 
L5940, L5981, L8420 and L8470).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on June 22, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that this should be covered. The Plan denied your 
request. The Plan says the services in this case are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90471) provided on June 22, 2022.  
 
Benefits for the vaccine services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on April 28, 
2021. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies. 
 
You asked the Plan to pre-approve diabetic supplies. You say that you would like the Plan to approve these 
supplies. The Plan denied your request. The Plan says these supplies have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve diabetic supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness exam provided on October 4, 2022. 
 
You asked the Plan to pay for the annual wellness exam. You say that your doctor orders an exam every 4 
months. The Plan denied your request. The Plan says the benefit maximum was exceeded with the 
October 4, 2022 visit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness exam provided on  
October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on September 16, 2022, billed with code 61782. 
 
You asked the Plan to pay for the services as billed. You say that this is correctly coded and should be paid. 
The Plan denied your request. The Plan says that 61782 is not billed with an appropriate primary code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not supported the denial rationale in this case. Though 61782 is an 
add-on code, it does not have a specific list of primary codes that are allowed. Review of the file shows that 
this stereotactic navigation was performed alongside the paid code 62143. No evidence was presented to 
support that this is not an allowed primary code for 61782. Therefore, we decided that the Plan has to pay for 
the services provided on September 16, 2022, billed with code 61782.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on April 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care rendered on April 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 5, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291. 
 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 93042 
is a column II code to column I code 99291. 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 93042 billed for date of service March 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 88112 for April 20, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 88112 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88112 is cytopathology, selective cellular enhancement 
technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal. 
 
We find that CPT code 88112 is not supported in the medical record. Specifically, there is no documentation 
that the services were performed for the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services billed with code 88112 for April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures do not fit, and the 
adhesive caused blisters resulting in weight loss. Your doctor advised you that if you continue to lose weight 
you will die. 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 April 7, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 55866 for April 23, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 12, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical services billed with code 55866 for April 23, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are medically necessary. 
The Plan denied your request. The Plan says the requested IRF services 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 that 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 may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the 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 
IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services with an out-of-network provider to 
be provided at the in-network benefit level. 
 
You asked the Plan to pre-approve physician's services with an out-of-network provider to be provided at the 
in-network benefit level. You say that  The Plan denied your request. The Plan says that the Health Plan has no 
previous records of services being provided to the enrollee from the out-of- network provider at issue. The 
Health Plan confirmed there is no reason as to why to the enrollee does not want to use the in-network provider 
and there is no medical reason to why she must use the out of network provider. The Health Plan confirmed 
with in-network provider that they will be able to provide the requested procedure. The in-network provider 
confirmed they can see the enrollee as soon as within a week and can perform the requested service. Therefore, 
the Health Plan does not have a network deficiency. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services with an out-of-network provider to be provided at the in-network benefit level.
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 requires intense physical and 
occupational therapy and close nursing care. The Plan denied your request. The Plan says admission to the 
acute inpatient rehabilitation setting have not been met, medically necessary care may be provided safely in a 
different level of care. 
 
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 the 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 pay the full cost for a crown - porcelain/ceramic tooth #13 (D2740) 
provided on September 28, 2022. 
 
You asked the Plan to pay full cost for the dental services. You say that you should not be responsible and the 
dentist should absorb the difference. The Plan denied your request. The Plan says the claim was processed 
correctly.  
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 contract also says you pay 50% coinsurance after $100 deductible has been met for all Class 3 major 
services, such as crowns. The Plan contract also states that if the Plan determines that a less expensive alternate 
procedure, service, or course of treatment can be performed in place of a proposed treatment; then the 
maximum the Plan will allow will be the charge for the less expensive treatment. The Plan determined that a 
crown with a metal base (D2751), which has an allowed amount of $964, could have been provided in place of 
the ceramic crown (D2740), which has an allowed amount of $1,100. You are responsible for the $136 
difference in allowed amounts, the $100 deductible, and 50% of the remaining allowed amount ($864 x 50% = 
$432) for a total responsibility of $668. 
 
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 processed as the least expensive alternate procedure 
that resulted in a professional result. Therefore, we decided that the Plan does not have to pay the full cost for a 
crown - porcelain/ceramic tooth #13 (D2740) provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided August 4, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that please review and reconsider 
this claim for payment. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the automatic external defibrillator was not filed until November 7, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, Synvisc or Synvisc-One 
injection. 
 
You asked the Plan to pre-approve hyaluronan or derivative, Synvisc or Synvisc-One injection. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyaluronan acid therapies are only covered 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 hyaluronan or derivative, Synvisc or 
Synvisc-One injection. Our reviewer says that the documentation does not support that the requested services 
are medically reasonable or necessary. Our physician reviewer found the enrollee has knee pain and a diagnosis 
of osteoarthritis of her left knee. The enrollee has failed conservative management. The documentation does 
not fully clarify that the provider's level of training meets the criteria cited above including documentation of 
trainee competency assessment by formal examination and case history document review. Therefore, the 
enrollee does not meet criteria for the requested 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 hyaluronan or derivative, Synvisc or Synvisc-One injection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyaluronan or derivative, Synvisc or Synvisc-
One injection.