Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0500 the moderate sedation services 
(99153) provided May 6, 2021 to May 21, 2021. 
 
You asked the Plan to pay for procedure code G0500 the sedation services. You say that you have attached 
medical records and reconsideration request. Please review. The Plan denied your request. The Plan says place 
of service inappropriate for procedure. 
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 99153 is  moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service).  
 
We find that CPT code 99153 is not supported in the medical record. Specifically, the work (or professional) 
component of physicians' services refers to the resources used in furnishing the service that reflect physician 
time and intensity. The technical component (or practice expense [PE]) refers to the portion of resources 
involved in furnishing services (such as equipment costs, office rent, and wages of personnel). As part of the 
CY 2017 Final Rule, CPT code 99153 was established as a PE-only code meaning there is no work component 
RVU associated with that service. As part of the CY 2017 Final Rule, CPT code 99153 was established as a 
PE-only code meaning there is no work component RVU associated with that service. The CY 2017 Final Rule 
established CPT codes 99151, 99152 and 99155-99157 as representative of the work component for moderate 
sedation services. This is further reflected in the 2021 National Physician Fee Schedule Relative Value File 
April Release with CPT code 99153 assigned a PC/TC indicator of 3 and a Work RVU of 0.00. Based on this 
information, we decided that Medicare rules for coverage of the sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0500 the moderate sedation 
services (99153) provided May 6, 2021 to May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering (L5962) for 
use with an approved leg prosthesis. 
 
You asked the Plan to pre-approve the flexible protective outer surface covering (L5962). You say that the 
requested leg and accessories are necessary to allow safe ambulation. The Plan denied your request. The Plan 
says the request has been approved aside from the L5962 protective covering which is not shown to be 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer coverings, such as those 
described by L5962, are only needed for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection offered by the standard coverings.  
We looked at the file and the Medicare rules. There is no specific documentation which details that the enrollee 
uses the prosthesis in unusually harsh environmental conditions. She is noted to be a level 2 ambulator which 
indicates only limited community ambulation. Without a specific need for additional protection beyond what is 
offered by the standard covering, we find this item to not meet coverage criteria. Therefore, we decided that the 
Plan does not have to pre-approve a flexible protective outer surface covering (L5962) for use with an 
approved leg prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
21, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your 
benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance (D4910) is 
limited to three procedures per plan year. The record shows that you received a periodontal maintenance 
(D4910) on January 14, 2021, March 3, 2021, and May 20, 2021 and your periodontal maintenance (D4910) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, lateral positioning wedges, mounting block, and privacy bag for a power wheelchair.  
You asked the Plan to pre-approve expandable controller, harness, electronic connection, lateral positioning 
wedges, mounting block, and privacy bag. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for these components is correct, because the 
enrollee's upper limb strength and function are adequate to use the wheelchair's power options with their own 
switches, the lateral positioning wedges and mounting blocks are already included in the approved components, 
and the privacy bag is not primarily medical in nature so is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose. 
 
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 expandable controller, harness, 
electronic connection, lateral positioning wedges, mounting block, and privacy bag. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records support that the enrollee is independent with grooming and hygiene, thus indicating 
that the enrollee had adequate left upper extremity strength and function to operate the wheelchair's power 
options. 
 
We looked at this physician's review, the file, and Medicare rules. The lateral positioning wedges and mounting 
block are already included in the approved components so do not need to be separately covered. The privacy 
bag at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to 
the general public and would be helpful even to those who are not sick or injured.  Based on this information, 
we decided that Medicare rules for coverage of expandable controller, harness, electronic connection, lateral 
positioning wedges, mounting block, and privacy bag have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller, harness, electronic connection, lateral positioning 
wedges, mounting block, and privacy bag for a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography, of the extremity, unilateral, radiological 
supervision and interpretation (75710) rendered by the out-of-network (OON) provider on April 12, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the angiography, of the extremity, unilateral, radiological supervision and 
interpretation (75710) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751) for tooth #20. 
 
You asked the Plan to pre-approve the crown. You say that your provider recommended you get a crown, 
otherwise the tooth will fall out completely. The Plan denied your request. The Plan says that a crown is not 
needed to fix your tooth. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Although it appears that dental x-rays were submitted to the Plan for review, the 
Plan did not forward these digital x-rays to us. Instead, poor quality photocopies of x-rays were submitted. We 
find that a photocopy of an x-ray is not a reasonable substitution for the original digital x-rays used by the Plan 
to makes its decision. For this reason, we find that the Plan failed to make a reasonable and diligent effort to 
substantiate its denial. Therefore, we decided that the Plan has to pre-approve a crown (D2751) for tooth #20.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on October 
12, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that authorization is not needed, 
and the claim should be reprocessed. The Plan denied your request. The Plan says the claim reprocessed to pay 
for CPT codes 97140 and 97110. The Plan also says that CPT code 97010 remains denied as bundled services 
are not eligible for separate reimbursement. 
 
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 97010 is application of a modality to 1 or more areas; hot 
or cold packs.  
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status 
indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the hot or cold packs therapy (97010) have not 
been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) 
provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), initial 15 minutes of deep sedation 
(D9222), additional 15 minutes of deep sedation (D923), and therapeutic parenteral drugs (D9612) provided on 
August 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were needed as a result of an auto 
accident many years ago. You also say that the services should be covered under your medical coverage. The 
Plan denied your request. The Plan says the services you received are considered routine dental. there is a 
$2,000 allowance for covered dental services. The Plan also says that the $2,000 dental allowance has been exhausted.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are listed as covered, 
the routine dental maximum allowance of $2,000 had been exhausted prior to the date of service in this case. 
Additionally, deep sedation services and therapeutic parenteral drug are not listed as covered. Therefore, we 
decided that the Plan does not have to pay for the extraction (D7210), initial 15 minutes of deep sedation 
(D9222), additional 15 minutes of deep sedation (D923), and therapeutic parenteral drugs (D9612) provided on 
August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick system (K1006). 
 You asked the Plan to pre-approve a PureWick system. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says medical necessity rules for the requested item have 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 a PureWick system. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that PureWick is not a covered device and external collection devices, and pads are 
available. There are no peer-reviewed articles published in the medical literature specific to the PureWick 
system or external urinary collection system using a continuous low-pressure pump. There is no evidence to 
show the PureWick system to be an effective alternative in managing urinary incontinence. 
 
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 PureWick system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PureWick system (K1006).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056), implant supported 
crown (D6065), and surgical placement: transosteal implant (D6050). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says implants and associated services are excluded from dental coverage. 
 
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 implant and related 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve prefabricated abutment (D6056), implant supported crown (D6065), and surgical placement: 
transosteal implant (D6050).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
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 for the spinal cord stimulator trial. Our reviewer says 
that the criteria for coverage of the requested services have not been met. Our physician reviewer found there is 
no evidence provided of a psychiatric evaluation. This evaluation is a required prerequisite before coverage 
will be approved. 
 
We looked at this physician's review, the file, and Medicare rules. The file does not show that a psychological 
evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. Therefore, we 
decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this is medically necessary for 
your condition. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is statutorily non-
covered because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. This device is statutorily non-covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 28, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you went to your dentist due to an injury that 
was causing a lot of pain. You say that you received the care that you needed. You also say that you feel the 
treatment was necessary. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per 
plan year. The Plan also says the frequency limit has been exceeded. 
 
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 and limited oral evaluation is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on Jun 23, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you do not have a lot of 
money and cannot afford dentures. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve a 
complete maxillary denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 2, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 2, 2022, 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 March 
2, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 2, 2022, forward. Our physician reviewer found the enrollee 
did not require inpatient mental health treatment beyond March 2, 2022, 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 enrollee's 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 March 2, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 2, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 29 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the implants are necessary. The Plan 
denied your request. The Plan says dental implants are specifically excluded from dental coverage. 
 
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 implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants 
(D6010) for teeth # 29 and 30.