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

 
We decided that the Plan does not have to pay for the x-ray provided on September 1, 2022. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the claim was billed with 
the incorrect diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  
 
We looked at the file and Medicare rules. The services in this case were billed with diagnosis codes M16.11 
and M16.12. As a bilateral diagnosis code exists for this condition, it is inappropriate to bill the left-sided and right-sided codes separately. Based on this information, we decided that Medicare rules for coverage of the x-
ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray provided on 
September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 2d photographic 
images (D0350), gingival irrigation (D4921), and unspecified periodontal procedures (D4999) provided on 
August 24, 2022, October 28, 2022, and November 2, 2022. 
 You asked the Plan to pay for the dental services. You say that you had inflammation of the gums, and the 
dental services were medically necessary. The Plan denied your request. The Plan says your benefit for the 
comprehensive oral evaluation has already been exhausted. Also, the denial of payment for the 2d photographic 
images, gingival irrigation, and unspecified periodontal procedures is correct because they are not covered by 
the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted the on date of service of July 8, 2022. 
The 2d photographic images, gingival irrigation, and unspecified periodontal procedures are not covered under 
the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), 2d photographic images (D0350), gingival irrigation (D4921), and unspecified periodontal 
procedures (D4999) provided on August 24, 2022, October 28, 2022, and November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96365 billed for date of service September 9, 
2022. 
 You asked the Plan to pay for procedure code 96365. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 96365 is bundled into payment for code 40808. 
 
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 96365 
is a column II code to column I code 40808. 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 96365 billed for date of service September 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on October 5, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56973. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the testing provided on October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 1, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 1, 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 1, 
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 1, 2023, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond April 1, 2023, as he was not a danger to himself 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 1, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 1, 2023, 
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor ankle foot system (L5973) for the enrollee.
You asked the Plan to pre-approve a microprocessor ankle foot system. You say that this microprocessor ankle foot system is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the requested equipment exceeds the enrollee's needs.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a microprocessor ankle foot system. Our Medical Director states that there is not sufficient clinical documentation in the case file of functional need for the technologic or design features of the requested foot/ankle system. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a microprocessor ankle foot system. 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 microprocessor ankle foot system have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor ankle foot system (L5973) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered in a long-term care 
facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair and accessories are being requested for use in a SNF. Therefore, we decided 
that the Plan does not have to pre-approve a wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the claim originally 
submitted. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. 
 We find that CPT code 99220 is not supported in the medical record. The medical records show that the 
enrollee was alert with no issues reported following knee surgery. The records do not show that medical 
decision making of high complexity was provided. 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 procedure code 99220 billed for date of service May 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93308 billed for date of service July 20, 
2022.  
You asked the Plan to pay for procedure code 93308. You say that this is a separate episode of care. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93308 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93308 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93308 billed for date of service July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with upgraded electronics. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with upgraded electronics. You say that please 
reconsider your original decision and approve the group 3 K0861 wheelchair base and all accessories 
requested. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple 
power options included with K0861 group 3 power wheelchair. The power elevating leg rests and upgraded 
electronics are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: a neurological condition, myopathy or a congenital 
skeletal deformity.  
 
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 Group 3 power wheelchair with upgraded electronics. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records do not document the 
enrollee has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at 
the knee, or the enrollee has significant edema of the lower extremities that requires a power elevating leg rest. 
The provided records do not support that the enrollee is high risk for skin breakdown. The enrollee is reported 
to be independent with transfers, has a history of pressure ulcers or has had skin flap surgery. The records do 
not document the enrollee performs bladder self-catheterization and is unable to transfer independently or has 
increased muscle tone or spasticity severe enough to meet criteria for the power tilt and/or recline or the 
multiple power option. The provided records document that the enrollee has 3+/5 right upper extremity strength 
and is independent with eating, thus, indicating the enrollee has adequate upper extremity strength and function 
to operate the wheelchair's power options with their own switches. 
 
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 Group 3 power wheelchair with upgraded electronics have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with upgraded 
electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulation supplies billed with codes 
E0730 and A4595 for December 3, 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 services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the electrical nerve stimulation supplies 
billed with codes E0730 and A4595 for December 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic 
substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural 
or subarachnoid, lumbar or sacral caudal; with imaging guidance (62323). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESI's are medically necessary when the criteria listed 
in the Medicare Rules section is met. 
 
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 epidural steroid injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of recent physical therapy (PT), Chiropractic and other conservative therapy. There is also no 
surgical consultation. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic substance(s), not including 
neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or 
sacral caudal; with imaging guidance (62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on October 27, 2022. 
 
You asked the Plan to waive the coinsurance for D7210. You say that you disagree with the coinsurance and 
would like the plan to reconsider. 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 50% 
coinsurance for restorative and extraction services.  
 You have been asked to pay a 50% coinsurance for D7210. This service falls within the dental services - 
supplemental 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 coinsurance for an extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member is 
receiving the appropriate care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that an LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36225 billed for date of service June 16, 
2022. 
 
You asked the Plan to pay for procedure code 36225. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 36225 is bundled into payment for code 36226. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 36225 is a column II code to column I code 36226. While code 
36225 was billed with modifier -59, the medical records provided do not show that the service billed with the  
-59 modifier is a distinct procedural service. 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 36225 billed for date of 
service June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 21, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the item is not a covered benefit in this place of 
service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on September 1, 2022. 
 
You asked the Plan to pay for the shoulder orthosis. The Plan denied your request. The Plan says the 
documentation submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the date of service in question and the supplies provided in this case. The records show that the item was shipped on August 31, 2022, and delivery one 
September 2, 2022. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis provided 
on September 1, 2022.
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 December 16, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that your doctor called to get the okay for the shot 
before you got it. The Plan denied your request. The Plan says the vaccines services are not covered under 
Medicare or the Plan. 
 
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 December 16, 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.