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

 
We decided that the Plan does not have to pay for the surgical services rendered on June 29, 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 codes 37220, 75625, and 37222 are 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 37220 is revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. The definition of code 75625 
is aortography, abdominal, by serialography, radiological supervision and interpretation. The definition of code 
37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac 
vessel; with transluminal angioplasty (List separately in addition to code for primary procedure). 
 We find that CPT codes 37220, 75625, and 37222 are not supported in the medical record. Specifically, there is 
no documentation of an open or percutaneous endovascular revascularization for the initial vessel to support 
code 37220. There is no documentation of radiological supervision and interpretation of an abdominal 
aortography by serialography to support code 75625. There is no documentation of a bilateral angiography of 
an extremity with radiological supervision and interpretation to support code 75716. 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 surgical services rendered on June 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal bone allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 the allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via cell composite allograft is experimental. More research is needed. Conventional allograft or 
autograft is all that is needed in this case. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the spinal bone allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty, glenohumeral joint; hemiarthroplasty 
(23470) arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total 
shoulder]) (23472). 
 
You asked the Plan to pre-approve reverse total shoulder arthroplasty. You say that you are appealing the 
denied shoulder surgery. The Plan denied your request. The Plan says there is no clinical evidence to support 
the medical necessity of this the device or that the member meets Medicare criteria. 
 
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 reverse total shoulder arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for primary osteoarthritis of the left 
shoulder. The enrollee presented with left shoulder pain that is aching and rated at 5. The left shoulder exam 
reveals active abduction of 20 and forward flexion to 40. Impingement testing is positive. However, detailed 
documentation is not evident regarding any previous shoulder procedures having been performed on the left 
shoulder. Additionally, the documentation does not corroborate that the rotator is irreparable. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested reverse total shoulder arthroplasty, in this 
case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reverse total shoulder arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve arthroplasty, glenohumeral joint; hemiarthroplasty (23470) 
arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total 
shoulder]) (23472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on September 21, 2022. 
 
You asked the Plan to pay for an intraoral x-ray (D0220). You say that you called the Plan on the day of your 
appointment and was told that this provider was a Plan provider. The Plan denied your request. The Plan says 
there is no coverage for intraoral x-rays (D0220). 
 
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 an 
intraoral x-ray (D0220) provided on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a 
stealth height adjustable receiver (K0108) and a pretty in pink joystick armor (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has a medical history 
including but not limited to spastic paraparesis, multiple sclerosis, neurogenic bladder with foley catheter, and 
impaired cardiovascular status. She is non ambulatory, dependent for Hoyer lift transfers, dependent with 
sitting balance and sits with asymmetries. The Plan denied your request. The Plan says the requested height 
receiver is part of the armrest already included with the power tilt and recline. Although there are three 
approved power options on this wheelchair, there is not a medical need to control these power options through 
the joystick. The Plan also says the joystick armor does not service a medical purpose and cannot be 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. Based on this information, we decided that Medicare rules for 
coverage of wheelchair accessories have not been met. The enrollee does not meet criteria for approval of the 
joystick armor as it does not serve a medical purpose. The enrollee does not meet criteria for approval of the 
height receiver as it is part of the already approved power tilt and recline. The records show the enrollee is 
diagnosed with paraplegia which is lower limb weakness. The enrollee has upper strength to control the power 
options already approved with the wheelchair. Therefore, we decided that the Plan does not have to pre-
approve an electronic connection between wheelchair controller and two or more power seating system motors 
(E2311), a harness (E2313), an expandable controller (E2377), a stealth height adjustable receiver (K0108) and 
a pretty in pink joystick armor (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a polyurethane 
seat liner (K0108) and gel arm rest pads (K0108). 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says a power seat elevator is not covered because it is not primarily medical in 
nature. The Plan also says they cannot approve the wheelchair component/accessory associated with the power 
seat elevator because items for appearance, convenience, or comfort are not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The power seat 
elevation system is not medical in nature and not covered by Medicare or the Plan. The seat liner and gel arm 
rest pads are not medically necessary and considered a convenience or comfort items. The records show that 
you were already approved for arm rests with standard pads. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system (E2300), a polyurethane seat liner (K0108) and gel arm rest pads 
(K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 81345 billed for date of service May 19,
2022.

You asked the Plan to pay for procedure code 81345. You say that these services were necessary and are
supported in the medical record. The Plan denied your request. The Plan says payment for code 81345 is
bundled into payment for code 0089U.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81345
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for procedure code 81345 billed for date of service May 19, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional radiographic image (D0230) provided on 
January 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that when you made the appointment the dentist was 
in-network. You also say that after your appointment you received a bill stating the dentist was out-of-network. 
The Plan denied your request. The Plan says your benefit for the intraoral - periapical each additional 
radiographic image (D0230), 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 intraoral - periapical each additional radiographic image (D0230) was exhausted on 
the claim appealed. Therefore, we decided that the Plan does not have to pay for the additional radiographic 
image (D0230) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (x2) (D2950) 
and pontic - porcelain/ceramic (D6245) provided on October 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you have been overcharged for the billed services. 
The Plan denied your request. The Plan says these services are not covered under your Plan. 
  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. Core buildup, including any 
pins when required (D2950), pontic - porcelain/ceramic (D6245) are not covered under the Plans dental 
benefits. 
 
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 core 
buildup, including any pins when required (x2) (D2950) and pontic - porcelain/ceramic (D6245) provided on 
October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite-four or more surfaces, posterior 
(D2394) provided on October 5, 2022. 
 
You asked the Plan to pay for a resin-based composite-four or more surfaces, posterior (D2394). You say that 
the Plan paid for the two least expensive fillings, and you cannot afford to pay the higher costs. 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 October 5, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite-four or more surfaces, 
posterior (D2394) provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 22, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you needed this service before you could 
have your extraction. The Plan denied your request. The Plan says the rendered dental service is not a covered 
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 pay for a limited 
oral evaluation (D0140) provided on September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility care. You say that the services were medically necessary 
due to health conditions. The Plan denied your request. The Plan says services were provided by a non-contract 
provider who performed services without prior authorization from the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility care provided on 
September 8, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear stress test provided on April 15, 
2022. 
 
You asked the Plan to waive the copayment for nuclear stress test. You say that you never had to pay this in the 
past so you shouldnt have too now. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for nuclear stress test. This item/service falls within the 
Diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for nuclear 
stress test provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), periodontal 
maintenance (D4910), and bitewing x-rays (D0274) and does not have to pay for the topical application of 
fluoride (D1206) provided on October 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with processing of this 
claim. 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. The Plan also 
says that the topical application of fluoride (D1206) 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for a periodic oral evaluation, periodontal maintenance, bitewing x-rays received on October 25, 
2022. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The topical application of fluoride is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay more for a periodic oral evaluation (D0120), periodontal maintenance (D4910), and bitewing x-
rays (D0274) and does not have to pay for the topical application of fluoride (D1206) provided on October 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel laboratory services provided on August 
3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for general health panel laboratory services. You say that these services were 
medically reasonable and necessary for treatment. The Plan denied your request. The Plan says the plan 
requires utilization of network providers when possible and available and requires authorization prior to 
services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for general health panel laboratory services provided 
on August 3, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility care. You say that the services were medically necessary 
due to health condition. The Plan denied your request. The Plan says a non-contracted provider performed 
services without prior authorization from the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility care provided on 
September 22, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the member was diagnosed with 
Pneumonia, and they are receiving sepsis therapy due to respiratory weakness. You say that therapists want at 
least one more week. The Plan denied your request. The Plan says continued admission in skilled nursing 
facility does not meet the requirements for approval. 
 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in 
a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.