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

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the therapeutic CGM. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim does not include a valid 
physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the documentation does not include evidence that the prescribing physician discussed the medical necessity of the ordered equipment with the enrollee. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the therapeutic continuous glucose monitor (CGM).
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 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 
lumbar spinal surgery. Medical problems are stable. There are 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 you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), power 
standing system (E2301), electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), the chest support (K0108), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable 
controller, harness and electronic connector to 2 power options) are not medically necessary. They are 
necessary when there is a medical need to control power options though the joystick. The notes do not show a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. These switches can be made any size without asking for a separate request. They can be made 
from any material without asking for a separate request. All of this can be done without the need to use the 
joystick to control the power features. The standing system and seat lift do not serve a primary medical purpose 
and cannot be covered. Chest support is requested and approved; duplicate request for chest support cannot be 
covered. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system (CPT 
code E2300), power standing system (E2301), electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), the chest support (K0108), expandable controller (E2377), and 
harness (E2313).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services (76981, 76705) provided on 
December 21, 2021. 
 
You asked the Plan to pay for the ultrasound services. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edits exist between codes 76770 and 76981 and codes 76981 and 76705. Both PTP edits 
have a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate 
modifier was not billed with either PTP code edit. This claim was not billed as required by Medicare coding 
regulations. 
 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, we have confirmed that code 76981 
is a column II code to column I code 76770, and code 76705 is a column II code to column I code 76981. 
These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the ultrasound services (76981, 76705) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to base metal crowns (D2751) for teeth 
#6 and #11. 
 
You asked the Plan to pre-approve crowns. You say that these services are medically necessary, and these teeth 
are causing a lot of pain when you eat. The Plan denied your request. The Plan says these crowns are not 
medically necessary as your x-rays do not show that these teeth have decay or loss due to fracture involving 
more than 50% of the biting edge of the teeth. 
 
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 crowns 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 crowns. Our reviewer says that the 
documentation provided does not meet the criteria for crown restorations on teeth #6 and #11. Our physician 
reviewer found the documentation indicates that teeth #6 and #11 do not appear to have significant coronal 
breakdown due to caries or fracture to warrant crown restorations. 
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 crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve porcelain fused to base metal crowns (D2751) for teeth #6 and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA), S1, S2, and S3 (CPT 
code 64625 X 3). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says more than one type of procedure on the same day is not supported. The Plan 
states the clinical information provided describes a request for more than one type of procedure on a single day; 
therefore, the requested procedure is not indicated at this time. 
 
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 physician reviewer 
found this is considered an experimental/ investigational procedure. Therefore, the request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the radiofrequency ablation (RFA), S1, S2, and S3 (CPT code 64625 X 3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says this claim has not been sent to the enrollee's primary insurer, so the Plan is 
not yet responsible for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you 
to bill the enrollee's primary insurer in its letter to you dated March 18, 2022. As the secondary insurer, the 
Plan cannot be held responsible for the lab services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for lab services provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting IOL, surgical correction (V2788), 
provided on June 21, 2021. 
 
You asked the Plan to pay for the presbyopia correcting IOL, surgical correction. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
IOL, surgical correction (V2788), provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vision hardware. 
 
You asked the Plan to pre-approve the vision hardware. You say that the items should be covered. The Plan 
denied your request. The Plan says you have exceeded the Plan's maximum allowance for this service. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with up to a $550 allowance for vision hardware. 
 
We looked at the file and the Plan's rules. You have exceeded the Plan's maximum allowance for this service. 
Based on this information, we decided that the Plan's rules for coverage of the vision hardware have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the vision hardware.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with field of view of one full dental arch - maxilla, with or without cranium (D0366), endodontic 
therapy, molar tooth (excluding final restoration) (D3330), and prefabricated post and core in addition to crown 
(D2954) provided December 16, 2021. 
 
You asked the Plan to pay for the cone beam CT scan, root canal and prefabricated post and core. You say that 
these services were necessary, and your dental allowance should apply to the cost. The Plan denied your 
request. The Plan says these services are not covered under your 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 pay for the cone 
beam computed tomography (CT) capture and interpretation with field of view of one full dental arch - maxilla, 
with or without cranium (D0366), endodontic therapy, molar tooth (excluding final restoration) (D3330), and 
prefabricated post and core in addition to crown (D2954) provided December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (CPT code E2377), harness for 
upgrade to expandable controller (CPT code E2313), power seat elevation system (CPT code E2300), 
electronic connection between wheelchair controller and two or more power seating system motors (CPT code 
E2311), and attendant control (CPT code E2331). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The seat lift does not serve a medical 
purpose. This cannot be covered. An attendant control cannot be covered when a power wheelchair with a 
controller that is operated by your is covered. The upgraded electronics (expandable controller, harness and 
electronic connector to 2 power options) are not medically necessary. They are necessary when there is a 
medical need to control power options though the joystick. The notes do not show a medical need to control the 
options through the joystick. The power options can be controlled using their own switches. These switches can 
be made any size without asking for a separate request. They can be made from any material without asking for 
a separate request. All of this can be done without the need to use the joystick to control the power features. 
The seat wedges are already included with the approved cushion. These cannot be requested separately. 
Therefore, we decided that the Plan does not have to pre-approve expandable controller (CPT code E2377), 
harness for upgrade to expandable controller (CPT code E2313), power seat elevation system (CPT code 
E2300), electronic connection between wheelchair controller and two or more power seating system motors 
(CPT code E2311), and attendant control (CPT code E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional eight (8) acupuncture visits. 
You asked the Plan to pre-approve additional acupuncture visits. The Plan denied your request. The Plan says 
no more than 20 acupuncture treatments may be administered annually. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan has approved a total of twenty (20) 
acupuncture visits the year. Therefore, we decided that the Plan does not have to pre-approve an additional 
eight (8) acupuncture visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and an extraction (D7140) provided by an out-of-network provider on October 25, 2021, to 
November 23, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, and an extraction. You say that you 
thought you would be entitled to more. The Plan denied your request. The Plan says D0140, D0220, and D7140 
are not covered 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 pay for a limited oral evaluation (D0140), intraoral imaging (D0220), and an extraction (D7140) provided by an out-of-network 
provider on October 25, 2021, to November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 4, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950), and an intraoral imaging (D0220) 
provided by a participating provider on January 24, 2022. 
 
You asked the Plan to pay for a core build-up and an intraoral imaging. You say that you should not have to 
pay for this. The Plan denied your request. The Plan says D2950 and D0220 are not covered 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 pay for a core 
build-up (D2950), and an intraoral imaging (D0220) provided by a participating provider on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from an out-of-network provider 
on December 6, 2021. 
 
You asked the Plan to pay for the services. You say that you thought this provider was in-network. The Plan 
denied your request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services you received from an out-of-network provider on 
December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments - includes placement 
(D6057). 
 
You asked the Plan to pre-approve custom fabricated abutments. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered under your 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 
custom fabricated abutments - includes placement (D6057).