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

 
We decided that the Plan does not have to pre-approve a power tilt seating system. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you are 
able to shift your weight. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical 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 the requested services. Our physician 
reviewer found that you have chronic back and joint pain. You have been using a cane but have had multiple 
falls. You do not require positioning to manage spasticity, have high risk for skin breakdown or use intermittent 
catheterization. Therefore, the request is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power tilt seating system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and 
comprehensive oral evaluation - new or established patient (D0150) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the tooth extraction and comprehensive oral exam. You say that you are in a 
lot of pain and cannot eat. The Plan denied your request. The Plan says services provided by an oral surgeon 
are not covered. 
 
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 tooth 
extraction and comprehensive oral exam when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. In this case the services are requested to be performed by an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction and 
comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and comprehensive oral evaluation - new or established patient 
(D0150) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 22585, 22226, 20937, 20931, 22220, 22554, and 
63081. 
 
You asked the Plan to pay for codes 22585, 22226, 20937, 20931, 22220, 22554, and 63081. You say that these 
codes are supported in the records. The Plan denied your request. The Plan says these codes are not 
documented. 
 
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 22585 is arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace 
(List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22226 is 
osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional 
vertebral segment (List separately in addition to code for primary procedure). The CPT Code Manual definition 
of code 20937 is autograft for spine surgery only (includes harvesting the graft); morselized (through separate 
skin or fascial incision) (List separately in addition to code for primary procedure). The CPT Code Manual 
definition of code 20931 is allograft, structural, for spine surgery only (List separately in addition to code for 
primary procedure). The CPT Code Manual definition of code 22220 is osteotomy of spine, including 
discectomy, anterior approach, single vertebral segment; cervical. The CPT Code Manual definition of code 
22554 is arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other 
than for decompression); cervical below C2. The CPT Code Manual definition of code 63081is vertebral 
corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal 
cord and/or nerve root(s); cervical, single segment. 
 
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 codes 22585, 22226, 20937, 20931, 22220, 22554, and 
63081. Our reviewer says that these codes are not supported. Our reviewer found the submitted medical records 
are insufficient to verify that these specific services were provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 22585, 22226, 20937, 20931, 22220, 22554, and 63081 have not been 
met. Therefore, we decided that the Plan does not have to pay for codes 22585, 22226, 20937, 20931, 22220, 
22554, and 63081.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system represented by code 
L5828, a stance flexion feature represented by code L5845, a fluid stance extension represented by code 
L5848, a microprocessor control feature represented by code L5856, a shank foot system with vertical loading 
pylon represented by code L5987, and an above the knee sleeve suspension represented by code L5695. 
 
You asked the Plan to pre-approve an advanced prosthesis represented by codes L5828, L5845, L5848, L5856, 
L5987, and L5695. You say that providing any lesser performing prosthetic system than the one requested 
would be a reduction in care. You say that you are accustomed to the microprocessor prosthetic system and 
enhanced foot for performance of variable and advanced movements and stances to maintain performance of 
ambulatory status and activities of daily living. The Plan denied your request. The Plan says the items which 
remain in dispute do not meet the medically reasonable and necessary criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that an advanced prosthesis is covered for certain 
indications and when 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 advanced prosthesis. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a double 
amputee who uses a walker but works on his care and cooks among other activities. The enrollee is a Group 2 
ambulator, as the record clear indicates. The items which remain in dispute are not considered medically 
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 an advanced prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an endoskeletal knee-shin system represented by code L5828, a stance flexion 
feature represented by code L5845, a fluid stance extension represented by code L5848, a microprocessor 
control feature represented by code L5856, a shank foot system with vertical loading pylon represented by code 
L5987, and an above the knee sleeve suspension represented by code L5695.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Notal diagnostic test (ForseeHome).

You asked the Plan to pre-approve the Notal diagnostic test (ForseeHome). You say that the Notal diagnostic test (ForseeHome) is medically necessary. The Plan denied your request. The Plan says the Notal diagnostic test (ForseeHome) is experimental and investigational.

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 Notal diagnostic test (ForseeHome). Our reviewer says that the Notal diagnostic test (ForseeHome) is not considered medically reasonable and necessary in this case. Our physician reviewer found in accordance with Social Security Act, Section 1862, vision monitoring with the ForeseeHome test is still being studied to detect changes in vision with macular degeneration. It is currently experimental and investigational.  Therefore, it has not been shown to be at least as beneficial as existing and available standard medical practice for the monitoring of this enrollee's condition. The device is not medically necessary compared to other current standard options.


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 Notal diagnostic test (ForseeHome) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Notal diagnostic test (ForseeHome).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine transportation trips are necessary. The Plan denied your request. The Plan says that the benefit for routine transportation has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 100 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional hours for home health aide services effective October 27, 2022.

You asked the Plan to pre-approve additional hours for home health aide services. You say that additional hours for home health aide services is medically necessary. The Plan denied your request. The Plan says the Plan's records show that you need hands on help with personal care. You need two people to reposition you. You had an assessment of the amount of time needed to help you on August 22, 2022. HHA Service, 56 hours per week, exceeds the Plan's standards. Service units must not go over the amount needed. We have extended the approval of HHA, 56 hours per week, for your CCA Care Team to reassess your needs. For these reasons, HHA Service will be reduced on October 27, 2022.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 


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 additional hours for home health aide services. Our reviewer says that additional home health aide services are not medically necessary. Our physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. HHA services are not shown to be required to assist in the treatment of an acute illness or injury. As such, the requested HHA services are not medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional hours for home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional hours for home health aide services effective October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the right total 
shoulder arthroplasty (CPT code 23472). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the planned procedure listed under CPT code 23472 is not listed on the 
Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is 
currently approved as an ambulatory procedure and there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences 
any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on 
concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided documentation did not reveal any unstable medical condition 
or high-risk clinical situation that would suggest the enrollee would require inpatient services following this 
typically ambulatory procedure. There was no suggestion from the documentation that the enrollee would 
require hospital services that would likely cross two (2) midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care following the right total shoulder 
arthroplasty (CPT code 23472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator.

You asked the Plan to pre-approve a ventilator. 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. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that you have lung cancer. The record indicates that you have an oxygen saturation of 100%. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 5, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service March 25, 2021. Specifically, the 
Plan contract provides coverage for one comprehensive oral evaluation every three plan years. You previously 
received this service on March 25, 2021, that was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (MPI) stress test.

You asked the Plan to pre-approve a MPI stress test. 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 follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare.

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 MPI stress test. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no history of chest pains. There is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in this enrollee's clinical management.

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 MPI stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a myocardial perfusion imaging (MPI) stress test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the endodontic therapy, anterior 
tooth (excluding final restoration) (D3310) provided on July 14, 2022, and the prophylaxis - adult (D1110), 
periodic oral evaluation - established patient (D0120), and intraoral - periapical each additional radiographic 
image (D0230) provided on May 24, 2022. 
 
You asked the Plan to provide additional payment for the root canals, dental cleaning, periodic oral exam and 
periapical x-ray. You say that you would like these claims paid. The Plan denied your request. The Plan says 
you exhausted your dental benefit, and no further payment is due. 
 
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 root 
canals, dental cleaning, periodic oral exam and periapical x-ray up to your $1,000 annual maximum. 
 We looked at the file and Medicare rules. The Plan provided documentation showing that you have exhausted 
your full $1,000 allowance.  Therefore, we decided that the Plan does not have to provide additional payment 
for the endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on July 14, 2022, and 
the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and intraoral - 
periapical each additional radiographic image (D0230) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on August 31, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you believe these services should be 
covered. 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 
periodontal maintenance (D4910) provided by a participating provider on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction of an erupted tooth (D7210). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation (D0150) and an extraction of an erupted 
tooth (D7210). You say that you need to have a biopsy to check for cancer of your gum. The Plan denied your 
request. The Plan says this is not s 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. The Plan rules say that services must be performed by a participating 
general dentist. Services performed by an oral surgeon are excluded from this benefit. Therefore, we decided 
that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an extraction of an 
erupted tooth (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve therapeutic parenteral drug. You say that the requested services are the 
proper protocol and should be covered. The Plan denied your request. The Plan says therapeutic parenteral drug 
is not listed as a covered service. 
 
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 therapeutic parenteral drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve therapeutic parenteral drug (D9610).