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

 
We decided that the Plan does not have to pre-approve Coflex Interspinous device. 
 
You asked the Plan to pre-approve Coflex Interspinous device. You say that you disagree with the Plan's 
denial. 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 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 Coflex Interspinous device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has low back pain. The Coflex device is experimental. More 
research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Coflex Interspinous device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Coflex Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), an expandable 
controller harness (E2313) and an electrical connection between the wheelchair controller and two more motors 
(E2311). 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that without the requested wheelchair and 
accessories that allows for tilt and recline, the enrollee would be unable to manage BLE edema and could result 
in increased wounds and hospitalizations. The Plan denied your request. The Plan says although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377), an expandable controller 
harness (E2313) and an electrical connection between the wheelchair controller and two more motors (E2311).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve pontics (D6245) for tooth #'s 4, 8, 9, 26, 29, and 30 and retainer 
crowns (D6740) for tooth #'s 3, 5, 7, 10, 25, 27, 28, and 31. 
 
You asked the Plan to pre-approve the fixed bridges. You say that this proposed treatment is essential to 
improve the enrollee's overall health. The Plan denied your request. The Plan says that bridges are not allowed 
to correct the way the enrollee bites, and are not covered because of wear or fracture of the porcelain. The Plan 
also says information does not state there is any decay, which is part of the clinical criteria needed for bridges. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the fixed 
bridges 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 fixed bridges. Our reviewer says 
that the documentation provided meets the criteria for coverage for replacement fixed bridges in the maxilla 
and mandible. Our physician reviewer found the present bridges are defective and greater than 10 years old. In 
removing defective bridges, there is no alternative other than replacing them with new functional appliances. 
Our reviewer also found that since the abutment teeth would need new crowns, it is medically reasonable that 
fixed appliances are the treatment of choice and the standard of care. 
 
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 fixed bridges have been met. Therefore, we decided that the Plan has to pre-
approve pontics (D6245) for tooth #'s 4, 8, 9, 26, 29, and 30 and retainer crowns (D6740) for tooth #'s 3, 5, 7, 
10, 25, 27, 28, and 31.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March 
24, 2022. 
 
You asked the Plan to pay for code 99153. 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 rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, a personal item pouch (A9270). 
 
You asked the Plan to pre-approve a personal item pouch. You say that all wheelchair accessories are 
medically necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says the 
requested pouch does not service a medical purpose. This cannot be covered as it is not reasonable and 
necessary per Medicare criteria. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, a personal item pouch (A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
lumbar fusion surgery and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
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 the enrollee is approved for a lumbar fusion surgery. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
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 acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for non-invasive imaging (01922). 
 
You asked the Plan to pre-approve the anesthesia. You say that the anesthesia is medically necessary. The Plan 
denied your request. The Plan says the requested anesthesia is not medically necessary. 
 
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 anesthesia for non-invasive imaging (01922) have been met. Specifically, there was no documentation provided to support the need for anesthesia. 
Therefore, we decided that the Plan does not have to pre-approve anesthesia for non-invasive imaging (01922).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy sessions provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy sessions. You say that the full 20 PT sessions are necessary 
for the enrollee to return to daily function. The Plan denied your request. The Plan says the enrollee's daily 
tasks and motion will get better with exercise at home.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy sessions. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional therapy services are not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional physical therapy sessions provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator represented by code E2300, an 
expandable controller represented by code E2377, an access harness represented by code E2313, and an 
electronic connection represented by code E2311. You asked the Plan to pre-approve codes E2300, E2377, and E2311. You say that the records provided support 
the need for the items which remain in dispute. The Plan denied your request. The Plan says a seat elevator is 
non-covered. The Plan says that the expandable controller, the access harness, and the electronic connection are 
not necessary because there is not a need for the enrollee to control power options through a joystick. The Plan 
says that the enrollee's limb strength and function are adequate for him to control the power options using their 
own switches included in the allowance for the approved wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature.  
 
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 codes E2300, E2377, and E2311. Our 
reviewer says that the items which remain in dispute are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have adequate strength in your upper extremities to manage more 
than one switch. You have a left hemiparesis. You do not have quadriparesis. The expandable controller 
exceeds what is necessary to meet your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2300, E2377, and E2311 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a seat elevator represented by code E2300, an expandable controller 
represented by code E2377, an access harness represented by code E2313, and an electronic connection 
represented by code E2311.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on December 3, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the provider informed you the 
copayment was $290 for each x-ray. You say that you have never paid that much for an x-ray.  The Plan denied 
your request. The Plan says the $35 copayment applied is correct. 
 
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 $35 
copayment, per day, per provider for Medicare-covered x-ray services.  
 
You have been asked to pay $35 copayment for x-ray. An x-ray falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 copayment 
for an x-ray provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D7210, D5863, D6010, D6950) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D7210, D5863, D6010, D6950)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on February 1, 
2022, and does not have to waive the coinsurance for palliative treatment on tooth #19 (D9110) provided on 
February 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is billing you for services because 
the Plan issued an overpayment request to the provider. The Plan denied your request. The Plan says your 
benefit for periapical x-rays has already been exhausted. The Plan also says that you have been charged the 
correct cost sharing amount for palliative treatment. 
 
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 a periapical x-ray was exhausted on date of service February 1, 2022.  
 You have been asked to pay $50.50, which is 50% coinsurance of the allowed amount for palliative treatment 
received on February 11, 2022 ($101 allowed amount x 50% coinsurance = $50.50). Periapical x-rays and 
palliative treatment fall within the Dental Services 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 pay for 
additional periapical x-rays (D0230) provided on February 1, 2022, and does not have to waive the coinsurance 
for palliative treatment on tooth #19 (D9110) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular dentures (D5110, D5120) 
 
You asked the Plan to pre-approve the maxillary and mandibular dentures. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
maxillary and mandibular dentures (D5110, D5120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided by an out-of-
network provider on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) provided by an out-of-network provider on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that your current denture does not fit right. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 3, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
partial mandibular denture (D5214) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal maintenance (D4910) provided on May 10, 
2022. 
 
You asked the Plan to pay more for periodontal maintenance. You say that you have full coverage for two 
periodontal cleanings a year. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 70% 
coinsurance for in-network periodontal maintenance.  The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$65.39, which is 70% coinsurance of the allowed amount for periodontal maintenance ($93.41 allowed amount 
x 70% coinsurance = $65.39). Periodontal maintenance falls within the Dental Services 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 pay more for periodontal maintenance (D4910) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve denture sectioning. You say that you cannot sleep since you are in so much 
pain. The Plan denied your request. The Plan says fixed partial denture sectioning (D9120) is not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed 
partial denture sectioning (D9120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing procedures (83789) performed on a 
laboratory specimen on March 22, 2022. 
 
You asked the Plan to pay for validity testing. You say that you have provided medical records to support the 
services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing procedures (83789) performed on a laboratory specimen on 
March 22, 2022.