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

 
We decided that the Plan does not have to pay for resin-based composite  one surface, anterior (D2330), resin-
based composite-one surface, posterior (D2391) provided on December 19, 2022. 
 
You asked the Plan to pay for resin-based composites. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite  one surface, anterior (D2330), resin-based composite-one surface, posterior (D2391) 
provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee has a severe dexterity impairment making 
it so they cannot use a standard blood glucose monitor. You say that the enrollee has never been able to prick 
their own finger. You also say that the enrollee should not have to rely on another person to monitor her own 
blood glucose level. The Plan denied your request. The Plan says the provided documentation does not support 
that all the coverage criteria have been met. 
 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 use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival irrigation and drugs dispensed in the office 
(D4921, D9630) provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a gingival 
irrigation and drugs dispensed in the office (D4921, D9630) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle identified with code K0800. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
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.  
 
 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 power operated vehicle. Our reviewer 
says that the documentation does not support that the requested device is medically reasonable or necessary. 
Our physician reviewer found a clinical progress note dated January 24, 2023, indicated that the enrollee has a 
history of chronic pain with multiple back surgeries and placement of a spinal cord stimulator placement. The 
enrollee was noted to have tenderness upon palpation of the lumbar spine and a normal gait. A clinical progress 
note dated February 22, 2023, indicated diagnoses type II diabetes mellitus and diabetic neuropathy. There is a 
lack of clinical documentation indicating the enrollees level of mobility and physical examination findings, 
specifically with regards to motor strength in the upper and lower extremities. There is no indication that the 
enrollee cannot use a cane or walker for assistance with mobility or propel a manual wheelchair. There is also a 
lack of information as to whether the enrollee can safely operate the requested group 1 power mobility device. 
Therefore, the enrollee does not meet criteria for the requested device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle identified with code K0800.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 12, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 12, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
12, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of April 12, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond April 12, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 12, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 12, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342) for the 
lower left quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that your provider told you the requested 
services are needed before the 24 months. 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 the date of service of December 10, 
2021. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing 
(D4342) for the lower left quadrant.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine and cervical spine. 
 
You asked the Plan to pre-approve an MRI of the lumber spine and cervical spine. You say that you would like 
to have the requested MRIs done at the same time. The Plan denied your request. The Plan says an MRI of the 
lumbar spine and an MRI of the spinal canal are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumber spine. Our 
reviewer says that the requested MRI of the lumbar spine is not medically necessary. Our physician reviewer 
found that you had prior imaging done in 2018 that included pain radiographs showing degenerative disc 
disease and facet arthrosis with no fractures or other acute findings. The documentation does not show any 
radicular signs or symptoms such as fever, systemic symptoms, or current malignancy. You do not meet 
Medicare criteria for the requested MRI scans. 
 
   
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 MRI of the lumber spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine and cervical spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve PAE. 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. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PAE is not medically reasonable and necessary in this case. PAE is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated 
possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure 
outside of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical 
failure rate compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove resin-based composite - two surfaces, posterior (D2392) 
at the contracted rate. 
 
You asked the Plan to preapprove the dental services at the contracted rate. You say that this should be covered 
at the in-network rate. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 preapprove resin-based composite - two surfaces, 
posterior (D2392) at the contracted rate.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service June 
15, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the service is 
covered as an inpatient hospital service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that the enrollee was an inpatient at the time the services 
were provided. The services at issue are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance transportation billed for date of service June 15, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29823) rendered on July 
12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that 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, the CPT Code Manual definition of 
code 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure note cites a 
debridement procedure was performed in the glenohumeral joint, synovitic tissue was debrided, biceps tendon 
stump was debrided, and bursal tissue was debrided. Therefore, the records do support CPT 29823 in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical shoulder arthroscopy (procedure code 29823) rendered on July 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fecal occult blood test provided on 
April 7, 2022. 
 
You asked the Plan to waive the copayment for the blood test. You say that this test should be considered a 
preventative screening and you should not be charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 to $20 copayment for each Medicare-covered laboratory service. 
 
 
 According to Medicare the fecal occult blood test is not considered a preventative screening service. 
The enrollee has been asked to pay a $15.92 copayment for the blood test. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the fecal occult blood test provided on April 7, 2022.
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 enrollee meets Medicare criteria for an IRF 
admission and will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says the denial is upheld. 
 
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 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 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 
therapy 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798-XU, 87801-XU, and 
87641-XU provided on October 19, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798-XU, 87801-XU, and 87641-XU. You say 
that the medical records support the billing of codes 87481, 87653, 87798-XU, 87801-XU, and 87641-XU. The 
Plan denied your request. The Plan says the medical records do not support the billing of codes 87481, 87653, 
87798-XU, 87801-XU, and 87641-XU. 
 
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 procedure codes 87798-XU, 87801-XU, and 87641-XU. Our 
reviewer says that the medical records do not support the billing of codes 87798-XU, 87801-XU, and 87641-
XU. Our reviewer found procedure code 86741 is not supported. The record states that staph aureus was not 
tested. This code is not substantiated for the date in question. Procedure code 87801 is not supported. The 
documentation does not specify what the multiple organisms were that were tested and reported with this code. 
It is not supported that the organisms are not included in another test that was reported and approved. 
Procedure code 87798 is not supported. All organisms tested for this sample are included in procedure code 
87150. Modifier XU is not supported; these services are not unusual and non-overlapping. 
 
Additionally, we have confirmed that codes 87481 and 87653 are column II codes to column I codes 87150 and 
87801. These codes have not been billed with an appropriate modifier to bypass the edit. 
 
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 87481, 87653, 87798-XU, 87801-XU, and 87641-XU have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798-
XU, 87801-XU, and 87641-XU provided on October 19, 2022.
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 December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were charged for the emergency service 
rendered on December 13, 2022. 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 July 28, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 6, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 6, 
2022.