Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) for tooth #10 provided on September 
1, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you would like the Plan to cover the 
crowns. The Plan denied your request. The Plan says your benefit for the year 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 Plan's 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 annual maximum dental benefit was exhausted on the date of service of September 1, 2022. On 
August 30, 2022, the Plan paid $104 for the dental services. On September 1, 2022, the Plan paid $1,644 for 
the dental services. On September 19, 2022, the Plan paid $252 for the dental services which was processed 
prior to the claim for the date of service of September 1, 2022. For the year of 2022 the Plan paid $2,000 ($104 
paid + $1,644 paid + $252 paid) for dental services. Therefore, we decided that the Plan does not have to pay 
more for a crown (D2751) for tooth #10 provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the white crown with metal for tooth #s 5, 6, and 8 
(D2751). 
 
You asked the Plan to pre-approve the white crown with metal for tooth #s 5, 6, and 8 (D2751). You say that 
you are appealing this denial. The Plan denied your request. The Plan says the service does not meet criteria. 
 
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 the white 
crown with metal for tooth #s 5, 6, and 8 (D2751) when the services are medically necessary and reasonable.  
 
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 white crown with metal for tooth #s 
5, 6, and 8 (D2751). Our reviewer says that the services are not medically necessary. Our physician reviewer 
found that bone support needs to be at least 50% to provide sufficient stability to the tooth for a good long-term 
prognosis. Tooth #5 has less than 50% bone remaining and a crown would not be an acceptable 
restoration. Teeth #6 and #8 have 50% bone but are not in need of such extensive restoration, even after 
endodontic treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the white crown with metal for tooth #s 5, 6, and 8 (D2751) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the white crown with metal for tooth #s 5, 6, 
and 8 (D2751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power elevation system, height adjustable push 
handles, side guards, armrest bag, expandable controller with harness upgrade, attendant control, and electronic 
connection. 
 
You asked the Plan to pre-approve 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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules say that an expandable controller is used to control multiple power options. 
 
We looked at the file and Medicare rules. The requested power seat elevation system, adjustable height push 
handles, side guards, and armrest bag do not serve a purpose that is primarily medical in nature. The file shows 
that the expandable harness upgrade, electronic connection, and attendant control are not needed to control the 
approved power switches. Therefore, we decided that the Plan does not have to pre-approve a power elevation 
system, height adjustable push handles, side guards, armrest bag, expandable controller with harness upgrade, 
attendant control, and electronic connection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominoplasty (15847) and mastopexy (19316). 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our reviewer found that the available clinical 
documentation does not support that abdominoplasty and mastopexy are medically reasonable and necessary 
for the enrollee in this case. There is insufficient information describing a functional medical need for the 
requested surgeries.  

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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve abdominoplasty (15847) and mastopexy (19316).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital care provided from 
December 21, 2021, to January 17, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital care. You say that the inpatient psychiatric hospital 
care was medically necessary. The Plan denied your request. The Plan says the inpatient stay from  
December 21, 2021, to January 17, 2022 was not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient psychiatric hospital care provided 
from December 21, 2021, to January 17, 2022. Our reviewer says that the requested inpatient psychiatric 
hospital care is not considered medically reasonable and necessary in this case. Our physician reviewer found 
this 80-year-old female was admitted to the acute inpatient psychiatric hospitalization on October 9, 2022 with 
Unspecified Dementia with Behavioral Disturbance (Major Neurocognitive Disorder, Unspecified with 
Behavioral Disturbance). Based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal 
ideation, auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any 
acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided 
at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not 
have dangerousness to self or others and was compliant with her treatment. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and does not have 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 were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis beyond the date in question. Based upon review of the 
records provided for the admission of this enrollee does not meet the criteria for December 21, 2021 forward as 
this enrollee was not shown to be a danger to herself or others, delusions, auditory or visual hallucinations 
noted. This enrollee was cooperative/compliant with treatment while not showing any threats the safety. 
 
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 hospital care provided from December 21, 2021, to  
January 17, 2022 have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
psychiatric hospital care provided from December 21, 2021, to January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve an endoskeletal ankle foot system. You say that the enrollee suffers from 
back and hip issues making him a good candidate for the advanced technology microprocessor knee and foot. 
This prosthesis will allow the enrollee to regain and maintain function. He is willing to participate in training 
for use of the prosthesis. He can function at a level necessary to use the device. It is medically necessary that he 
receive a left transfemoral prosthesis with a microprocessor knee and K3 foot to maintain his independence. 
The Plan denied your request. The Plan says the requested code L5973 cannot be used for this specific named 
prosthetic component as it is unbundled and, therefore, cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code L5973 is not supported in the medical record. Specifically, the ankle foot system cannot 
be used for the named ankle foot prosthetic component. This specific prosthetic is considered unbundled. The 
manufacturer nor the vendor has the authority to assign this code to the requested knee or ankle foot system. 
Based on this information, we decided that Medicare rules for coverage of an endoskeletal ankle foot system 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal ankle foot 
system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source 
(L5973).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the enrollee is in pain. You 
say that they have severe arthritis. You also say that it is beyond repair without surgery. The Plan denied your 
request. The Plan says the requested inpatient admission is not medically necessary. 
 
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 admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the procedure associated with the requested inpatient admission is currently 
approved as an ambulatory procedure. The reviewer found there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. Therefore, the reviewer found that the 
requested inpatient admission is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. 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 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 admission are met in this case. Our physician reviewer found that detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the record does not show that at the time of inpatient admission, the admitting physician reasonable expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an electronic 
connection between wheelchair controller and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the requested power seat elevation 
system is not covered because it is not primary medical in nature. If a wheelchair has an electrical connection 
device and the sole function of the connection is for a power seat elevation or power standing feature, it will be 
denied as non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seat elevation system does not serve a purpose that is primarily medical in nature. Medicare rules 
say if a wheelchair has an electrical connection device described by code E2310 and if the sole function of the 
connection is for a power seat elevation system, it will be denied as non-covered. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation system (E2300) and an electronic connection 
between wheelchair controller and one power seating system motor (E2310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service January 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from August 
9, 2022, to August 26, 2022. 
 
You asked the Plan to pay for the SNF services. You say that the Plan should pay for these services. The Plan 
denied your request. The Plan says as of August 9, 2022, the patient had exhausted their SNF benefits. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 25, 2022, 
through June 28, 2022, and July 5, 2022, through August 8, 2022. The Plan has covered 100 days of SNF care.  
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided from August 9, 2022, to 
August 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95885, 95937, and 95908 provided 
on November 20, 2020. 
 
You asked the Plan to pay for procedure codes 95955, 95885, 95937, and 95908. You say that the medical 
records support the billing of codes 95955, 95885, 95937, and 95908. The Plan denied your request. The Plan 
says the medical records do not support the billing of codes 95955, 95885, 95937, and 95908. 
 
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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is Needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 
code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 
method. The definition of code 95908 is Nerve conduction studies; 3-4 studies. 
 
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 procedure codes 95955, 95885, 95937, and 95908. Our 
reviewer says that the medical records do not support the billing of codes 95955, 95885, 95937, and 95908. 
Our reviewer found based on the documentation provided, procedure code 95955 is not supported. The 
minimum technical standards for an EEG as defined by the ACNS require at least 6 channels of monitoring to 
be done. In this case a 2 channel EEG was done (using the SSEP leads). A 2 channel EEG is insufficient for 
clinical diagnostic utility. Given that this fails to meet the minimum technical standards for the code it is not 
supported. 
 
Procedure code 95885 is not supported as there was not a nerve conduction study done during the procedure. 
This would not have been the appropriate CPT code to have been used. 
 
Procedure code 95937 is not supported. In this case train of four testing was done. Testing of the 
neuromuscular junction to evaluate for a neuromuscular disorder was not done. This service was also not coded 
correctly. 
 
Lastly, procedure code 95908 is not supported. This service was incorrectly coded. It is considered part of the 
EMG service 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 procedure codes 95955, 95885, 95937, and 95908 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95955, 95885, 95937, and 95908 
provided on November 20, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes do not show a covered type of tremor. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that the enrollee has 
essential tremor. The neurosurgeon has requested computed tomography as a pre-op planning tool. Essential 
tremor is a well known entity and the test is needed for pre-op planning and should be approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) of the brain for the enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental for the treatment of back pain. More research is needed to support its efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.