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

 
We decided that the Plan does not have to pre-approve the conversion of a manual wheelchair to a power 
wheelchair. 
 
You asked the Plan to pre-approve the conversion of a manual wheelchair to a power wheelchair. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the conversion of a manual wheelchair 
to a power wheelchair have been met. Specifically, no medical records were provided to indicate the necessity 
of upgrading a manual wheelchair to a power wheelchair. Therefore, we decided that the Plan does not have to 
pre-approve the conversion of a manual wheelchair to a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance services billed with code D4910 for 
date of service November 29, 2021. 
 
You asked the Plan to pay for code D4910. You say that you were not aware there was a limit on periodontal 
maintenance. The Plan denied your request. The Plan says you already exhausted your benefit for code D4910. 
The Plan says this code is only covered twice per calendar year and you already received these services on May 
5, 2021, and August 16, 2021. 
 
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. The Plan's contract explicitly 
states that periodontal maintenance is only covered two times per year.  You have already received two covered 
periodontal maintenance services this year, so you are not eligible for additional coverage. 
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 services billed with code D4910 for date of service November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on June 16, 2021, 
billed with code 81479. 
 
You asked the Plan to pay for the testing as billed. You say that this is clearly a medically necessary test based 
on the ordering provider's judgement. The Plan denied your request. The Plan says this is a screening test that 
cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by a physician with 
whom the enrollee has an established relationship. 
Though there is a signed order from a physician, no records that were contemporaneous to this testing were 
submitted. In addition, no records from the ordering physician were included. As such, it is not clear from the 
records that the ordering physician has treated the enrollee for a specific medical problem nor that the results 
would be used in patient management. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on June 16, 2021, billed with code 81479.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee's 
pain is not caused by osteoarthritis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Synvisc-One. Our physician reviewer 
found that the enrollee had a right knee subchondral insufficiency fracture. In this case, there is no 
documentation of osteoarthritis of the right knee. The enrollee's knee condition is a result of trauma. The 
requested use of Synvisc-One is not FDA-approved for the enrollees diagnosis. Its use is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services billed with codes D4921 and D9630 for date 
of service December 6, 2021. 
 
You asked the Plan to pay for codes D4921 and D9630. You say that you paid for these out of pocket, so you 
don't know why the dentist billed your plan. The Plan denied your request. The Plan says these dental services 
are not covered under your dental 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. The Plan's contract says that 
the dental benefit includes coverage only for those dental services explicitly listed in the Mandatory 
Supplemental Dental Benefit Chart. Codes D4921 and D9630 are not listed as covered services in this chart. 
 
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 dental 
services billed with codes D4921 and D9630 for date of service December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 office visits to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that you realize you do not have dental coverage, 
but believe these services are medical issues as opposed to dental issues. The Plan denied your request. The 
Plan says the provider you are requesting to see is not in the Plan's network. The Plan also says that there is not 
a medically necessary reason that the services cannot be provided by an in-network provider. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. These services are not considered medical just because the work is needed due to an 
injury. Therefore, we decided that the Plan does not have to pre-approve 6 office visits to be rendered by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the patient had her lower intestine removed and has 
an infection.  You said that this patient lives alone and doesn't have any family members to help her and that 
she requires 24-hour supervision. You say that SNF services are needed for her to regain strength. The Plan 
denied your request. The Plan says the patient can be managed at a lower level of care. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with 
a small bowel obstruction and underwent small bowel resection. Currently, this enrollee has no skilled nursing 
needs.  While the enrollee would benefit from skilled hterapy, the documentation does not support that it is 
medically reasonable and necessary to provide skilled services on a "daily basis" on an inpatient basis, in a 
skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF care following a stroke to address 
your current deficits. The Plan denied your request. The Plan says you are unlikely to be able to tolerate 
intensive therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for a stroke and were discharged home with home health care. You have ongoing weakness, but your 
medical problems are stable. You have no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis. 
 
You asked the Plan to pre-approve the pelvic MRI. You say that it is felt that the pelvis should also be 
imagined due to severe groin pain. The Plan denied your request. The Plan says that imaging of just the 
abdomen is sufficient to evaluate the kidneys. There is no medical necessity to include the pelvic area. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pelvic MRI. Our reviewer says that 
the requesting pelvic imaging is considered medically reasonable and necessary in this case. Our physician 
reviewer found not only does this patient have polycystic kidney disease, she also has hematuria and right 
groin, hip pain. The inclusion of the MRI of the pelvis is reasonable as the bladder, pelvis, and the right hip will 
be in the field of view. The pelvis MRI should be approved along with the abdominal portion to provide 
information on these other symptoms. 
 
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 pelvic MRI have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the pelvis.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture you received on November 10, 2021, from an 
out-of-network dentist. 
 
You asked the Plan to pay for the denture. You say that You did not provide an argument with your appeal 
request, just documentation from the dentist. The Plan denied your request. The Plan says the provider you 
used does not participate with 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. the contract explicitly says 
that the Plan will only cover dental services from a Participating Provider.  You did not receive this denture 
from a Participating Provider. 
 
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 the 
denture you received on November 10, 2021, from an out-of-network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of the right iliac, tibial, and peroneal 
arteries. 
 
You asked the Plan to pre-approve the revascularization of the arteries at issue. You say that the enrollee would 
benefit from treatment of all the requested arteries. The Plan denied your request. The Plan says treatment is 
only medically necessary for the right popliteal artery. 
 
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 revascularization of the arteries at 
issue. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a female with peripheral vascular disease documented 
on computed tomography angiogram (CTA).  At issue is whether the requested authorization for revascularization of iliac/tibial/peroneal arteries is medically necessary. While the patient has peripheral vascular disease, with severe stenosis of 70-90% in the right proximal popliteal artery, for which authorization for revascularization has been approved, there is no evidence 
of greater than 50% stenosis in the right iliac, tibial or peroneal arteries. As such, there is no need for 
revascularization of these vascular segments. In summary, there is insufficient documentation to support the 
medical necessity for revascularization of the right iliac, tibial or peroneal arteries in this patient'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 the revascularization of the arteries at issue have not been met. Therefore, we 
decided that the Plan does not have to pre-approve revascularization of the right iliac, tibial, and peroneal 
arteries.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 7, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your dentist 
determined you need cleanings and evaluations every 4 months, but your plan only covers 2. You also say that 
you would like your plan to cover 3 cleanings and evaluations within the calendar year. The Plan denied your 
request. The Plan says these services exceed the frequency limitations 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, periodic oral evaluation (D0120) and 
prophylaxis (D1110) are each limited to two procedures per plan year. The record shows that you received 
periodic oral evaluations (D0120) and prophylaxes (D1110) on January 18, 2021, and August 4, 2021 and your 
periodic oral evaluation (D0120) and prophylaxis (D1110) benefits have been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on October 14, 2021, from an 
out-of-network dentist. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you have dealt with this dentist 
for years and consider this dentist the best in his field.  You said that you trusted this dentist to provide you 
with new teeth. The Plan denied your request. The Plan says out-of-network dental services 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's contract explicitly 
states that dentures are not covered if you receive them from an out-of-network dentist. 
 
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 dental 
services you received on October 14, 2021, from an out-of-network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adjustable REVO socket described by code L5999. 
 
You asked the Plan to pre-approve the adjustable REVO socket. You say that this REVO socket is needed due 
to the potential for large weight loss during use of the prosthesis. The Plan denied your request. The Plan says 
L5999 is requested as member's residual limb to allow member to adjust his prosthetic socket to prevent 
movement in prosthetic socket. This socket does not have approval from the Food and Drug Administration. 
 
The Plan must follow Medicare rules. Medicare rules say that use of code L5999 for any feature or function of 
a socket is denied as unbundling.  
 
The REVO socket cannot be approved as the use of code L5999 is not appropriate for any component of a 
prosthetic socket. Therefore, we decided that the Plan does not have to pre-approve the adjustable REVO 
socket described by code L5999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services (95885 and 95909) provided on 
April 28, 2021. 
 
You asked the Plan to pay for the monitoring services (95885 and 95909). You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the monitoring services (95885 and 95909) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided October 8, 2021. 
 
You asked the Plan to pay for the additional intraoral x-rays. You say that you would like this service covered. 
The Plan denied your request. The Plan says one intraoral-periapical film is allowed per calendar year, and this 
has been met. 
 
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. The Plan covers an intraoral x-
ray once per calendar year. 
We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray 
was covered on this same date of service. Based on this information, we decided that the Plan's frequency limit 
for coverage of the additional intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the intraoral - periapical each additional radiographic image (D0230) provided October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on November 3, 2021. 
 
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 code 77003 is 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 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 imaging services rendered on November 3, 2021.