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

 
We decided that the Plan does not have to pre-approve Revita. 
 
You asked the Plan to pre-approve Revita. You say that it is medically necessary for the enrollee to be 
authorized for the Human Amniotic membrane graft transplant. You say that there is possibility of infection, 
amputation and limb loss, or loss of life if not healed. You say that the clinical documentation provided clearly 
demonstrates medical necessity. The Plan denied your request. The Plan says the records do not show that the 
enrollee's wound measurements span a thirty-day period. The Plan says that the records do not show that the 
enrollee's nutritional status was reported with appropriate lab tests called albumin or prealbumin. The Plan says 
that 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 Revita. Our reviewer says that Revita is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
a diagnosis is type 2 diabetes mellitus with foot ulcer, stage 2 left ankle. The record says that the enrollee has 
had continued treatment of non-healing ulcer. Records were provided of measurements for January 12, 2023, 
and January 24, 2023. The documentation indicates that there is no evidence of a chronic wound that has failed standard treatment for at least a 30-day period, with skin deficit at least 1.0 centimeters squared in size. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Revita.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852, L2397). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the services. Our reviewer says that  
Our physician reviewer found that the documentation does not reveal objective physical exam evidence of knee 
instability. There is no evidence of recent injury or surgery to the knees. The patient is documented to be 
ambulatory however the criteria for the requested knee orthosis has not been met. 
 
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 a knee orthosis (L1852, L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #12 (D6010), a bone 
replacement graft on tooth #12 (D4263), and guided tissue regeneration on tooth #12 (D4266). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says an endosteal implant (D6010), a bone replacement graft 
(D4263), and guided tissue regeneration (D4266) are 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 an 
endosteal implant on tooth #12 (D6010), a bone replacement graft on tooth #12 (D4263), and guided tissue 
regeneration on tooth #12 (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture with a flexible base (D5225). 
 
You asked the Plan to pre-approve a partial denture. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says that a partial maxillary denture with a flexible base (D5225) 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial maxillary denture with a flexible base (D5225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (procedure codes 73552, 73560, 
73590, Q0092) provided to the enrollee on July 15, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the submitted medical records do not support radiologic examination, 
femur; minimum 2 views, radiologic examination, knee; 1 or 2 views, radiologic examination; tibia and fibula, 
2 view, and set up portable X-ray equipment. 
 
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 the denied codes is: 
 
73552 - radiologic examination, femur; minimum 2 views 
73560 - radiologic examination, knee; 1 or 2 views 
73590 - radiologic examination; tibia and fibula, 2 view 
Q0092 - set up portable X-ray equipment 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record only includes 
documentation of an ultrasound of the unilateral lower extremity veins. There is no record of an x-ray of the 
femur, knee, tibia, or fibula found in the records. As the x-rays were not supported, Q0092 and its modifiers 
also cannot be verified. 
 
We looked at this coder'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 pay for the radiology services (procedure codes 73552, 73560, 73590, Q0092) provided to the enrollee 
on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergent transportation over the 60-mile radius. 
 
You asked the Plan to pre-approve the non-emergent transportation over the 60-mile radius.. You say that you 
have a cataract surgery, and you need transportation. The Plan denied your request. The Plan says 
transportation trips over the 60-mile limit is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers trips that do not exceed 60 miles based on the most efficient route.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the service is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the 
non-emergent transportation over the 60-mile radius.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair and accessories. 
 
You asked the Plan to pre-approve the items. You say that the requested items are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested power wheelchair and accessories are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 items. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the records 
consistently that the enrollee has a scooter and uses it. The record is not consistent as to why the scooter is 
inadequate. The enrollee is able to walk and transfer. There are no objective measures of poor trunk control. 
 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 2 heavy duty power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the toes provided on September 4, 2022, billed 
with code 73660. 
 
You asked the Plan to pay for the x-ray of the toes. You say that you feel that this should be paid as billed even 
though you are not a Medicare provider. You state that you do not have a contractual agreement with the Plan 
so you are not required to accept their allowed rates. The Plan denied your request. The Plan says this claim 
was billed to a Medicare Advantage plan and was paid correctly based on the Medicare payment system. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 73660 has a status indicator of Q1 in the Outpatient Prospective Payment System (OPPS). This 
means that payment is packaged or bundled if billed on the same claim as a code with a status indicator of S, T, 
or V. Review of the claim shows that it was billed with code 99283 (which was paid). 99283 has a status 
indicator of V. As such, no separate payment is allowed for code 73660. Based on this information, we decided 
that Medicare rules for coverage of the x-ray of the toes have not been met. Therefore, we decided that the Plan 
does not have to pay for the x-ray of the toes provided on September 4, 2022, billed with code 73660.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of reconstructed breast. 
 
You asked the Plan to pre-approve revision of reconstructed breast. You say that the records provided support 
the need for the service which remains in dispute. The Plan denied your request. The Plan says, given the lack 
of functional impairment caused by the breast deformity, the requested surgery would be considered cosmetic 
and is not covered. 
 
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 revision of reconstructed breast. Our 
reviewer says that revision of reconstructed breast is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has previously undergone breast 
reduction after weight loss and has a dog ear deformity. The record does not indicate functional impairment or the presence of chronic intertrigo.  The record provided does not establish the medical necessity and 
reasonableness of the requested surgery.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revision of reconstructed breast have not been met. Therefore, we decided that 
the Plan does not have to pre-approve revision of reconstructed breast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower complete denture (D5120). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
dental item. 
 
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.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met.  
 Specifically, the Plan contract states that a complete lower denture, lower immediate denture, or lower partial 
denture is covered once every 60 months. Additionally, replacement of removable and fixed prostheses is 
covered only if the existing prostheses were inserted at least 60 months prior to the replacement and 
satisfactory evidence is presented that the existing prostheses are not and cannot be made serviceable. You 
previously received a lower partial denture on July 30, 2018. This item was provided to you less than 60 
months ago; therefore, you are not eligible at this time for the requested item. Therefore, we decided that the 
Plan does not have to pre-approve a lower complete denture (D5120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the ultrasound screening provided on 
June 7, 2022. 
 
You asked the Plan to pay for the ultrasound screening interpretation. You say that this should be paid. The 
Plan denied your request. The Plan says the diagnosis codes reported are not considered appropriate for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that ultrasound screening for AAA may be covered 
for patients in one of the risk categories listed in the Medicare rules section.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound screening interpretation have not been met. Specifically, neither the records nor the 
reported diagnosis codes demonstrate that the enrollee has one of the risk factors required for coverage. 
Therefore, we decided that the Plan does not have to pay for the interpretation of the ultrasound screening 
provided on June 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the spinal canal 
and contents, lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that you were being treated for 
radiculopathy of the lumbar spine. You presented with back pain that started more than one year ago. The pain 
is aching and burning. There are associated symptoms of weakness. The exam reveals lumbar spasms are 
present. However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures, including physical therapy or physician-directed 
exercises. Additionally, detailed evidence of severe and/or progressive neurological abnormalities has not been 
documented. Moreover, there are no x-rays provided that were non-diagnostic for the lumbar spine. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested diagnostic imaging in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested lumbar spine MRI 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI), of the spinal canal and contents, lumbar; without 
contrast material (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 document does not support necessity for admission to an IRF due to lack of 
medical or rehabilitation complexity with no acute rehabilitation nursing needs. While the enrollee may benefit 
from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can be provided 
in a lower intensity and alternate setting such as in a skilled nursing facility (SNF).  
  
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Keytruda is not FDA-
approved for your diagnosis based on PDL1 testing. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network primary care physician 
(PCP). 
 
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 available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network primary care physician (PCP).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 37226, 37228, 37253) 
provided to the enrollee on April 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported by the medical records submitted. 
 
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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
include sufficient to validate the denied codes. Additionally, the documentation does not support the use of the 
22 modifier. 
 
We looked at this coder'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 pay for surgical services (procedure code 37226, 37228, 37253) provided to the enrollee on April 6, 
2022.