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

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 1, 
2021. 
 
You asked the Plan to pay for procedure code 87634. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87631. 
 
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 87634 
is a column II code to column I code 87631. 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 87634 billed for date of service August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the codes are covered by Medicare. The Plan 
denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that a hereditary cardiovascular screening panel was 
provided. Screening tests for the early detection of cardiovascular disease are not covered. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is 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 or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #10. 
 
You asked the Plan to pre-approve a crown for tooth #10. You say that a filling has been placed several times 
but keeps falling out due to the enrollee's bite. You also say for proper restoration, the enrollee will need a 
crown placed on this tooth. The Plan denied your request. The Plan says there is no clinical evidence to support 
medical necessity. 
 
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 a crown for 
tooth #10 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 a crown for tooth #10. Our reviewer 
says that this request for a crown on tooth #10 does not appear to be reasonable and necessary. Our physician 
reviewer found there is about 30% damage to the tooth structure that has been previously restored. The 
provider indicated that the restorations placed previously had failed due to the occlusion.  Our reviewer found 
that given the amount of remaining structure visible on the x-ray, it would appear that a restoration placed with 
adequate bite adjustments would be functional in this situation. Our physician reviewer also found that as there 
is significantly more structure remaining than would be required for a crown consideration, there would be no 
necessity for the procedure. 
 
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 a crown for tooth #10 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown (D2740) for tooth #10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, a transit kit/tie 
down (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says durable medical equipment is covered if it is appropriate for use in the 
enrollee's home. The transit kit is used to strap the wheelchair to a vehicle to travel outside the home, therefore, 
it is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair component or accessory, a transit kit/tie down (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified 
(L5999). 
 
You asked the Plan to pre-approve HiFi Advanced Socket System. You say that the requested socket is 
medically necessary. The Plan denied your request. The Plan says the request for the prosthetic socket 
additions cannot be approved at this time by Medicare or your health plan. A HiFI socket system is included in 
the base code for an above knee prosthetic socket. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The file shows that the requested prosthetic socket additions are included with the requested prosthetic socket. 
A separate request for prosthetic socket additions is a duplicate request. Therefore, we decided that the Plan 
does not have to pre-approve a lower extremity prosthesis, not otherwise specified (L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections (20550, 20552, 20553), and a 
panoramic x-ray (70355). 
 
You asked the Plan to pre-approve the outpatient services. You say that treatment of your TMJ is medically 
necessary. You say that you cannot chew or talk without severe pain. You say that you have pain in your jaw and jaw clicking. You also say that this is interfering with your quality of life. The Plan denied your request. 
The Plan says that items and services related to Temporomandibular Joint (TMJ) Syndrome are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 outpatient services have not been met. Specifically, items and services for 
TMJ treatment are not covered. The record shows that you previously received a panoramic x-ray on May 25, 
2022. Therefore, we decided that the Plan does not have to pre-approve trigger point injections (20550, 20552, 
20553), and a panoramic x-ray (70355).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98940) billed for date of service April 
13, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the services at issue were billed correctly for 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 4, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for chiropractic services have not been met. Therefore, 
we decided that the Plan does not have to pay for chiropractic services (98940) billed for date of service April 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311), a power seat elevation system (E2300) and an addition to 
power seating system, center mount power elevating leg rest/platform (E1012). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee is unable to safely 
transfer or complete effective weight shifts for pressure relief throughout the day. The enrollee requires a group 
3 base with power tilt, rehab seating and power elevating leg rests to meet his mobility, pressure relief and tone 
management needs throughout the day. The Plan denied your request. The Plan says while the LCD notes that 
power elevating leg rests are indicated for use with recline, recline has been neither requested nor approved for 
this power wheelchair. Power elevating leg rests are needed if 90-degree flexion is prevented at the knee, if the 
enrollee has lower limb edema, or if the enrollee has a reclining wheelchair. Although there are three power 
features requested on this wheelchair, only one power tilt can be approved. As two or more power features 
cannot be approved. The seat elevation system does not serve a primary medical purpose and is statutorily non-
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 power wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not have a condition which requires power leg rests per 
Medicare, power seat elevation is considered not medically necessary, and the expandable controller is not 
medically necessary because he has adequate upper body capacity to manage multiple power drives. He does 
not have impaired upper extremity or strength, and he does not have edema or impaired flexion of knees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311), a power seat elevation system (E2300) and an addition to power seating 
system, center mount power elevating leg rest/platform (E1012).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core buildup (D2950 x 2), pontic 
(D6245) and retainer crown (D6740 x 2) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a review of your claim and 
reevaluation of the denial. The Plan denied your request. The Plan says these services are not covered by the 
Plan's 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 the crown 
(D2740), core buildup (D2950 x 2), pontic (D6245) and retainer crown (D6740 x 2) provided on May 24, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided February 14,
2020, to February 24, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that you disagree with the Plan's
denial. The Plan denied your request. The Plan says the services are not payable 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 find that the skilled nursing facility services are not supported in the medical record. Specifically, an
invalid Health Insurance Prospective Payment System (HIPPS) code was billed for the skilled nursing facility
services rendered. Based on this information, we decided that Medicare rules for coverage of the skilled
nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for the
skilled nursing facility services provided February 14, 2020, to February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral exam (D0120) and dental cleaning 
(D1110) provided July 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that your dentist was 
no longer participating. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 the periodic oral exam (D0120) and dental 
cleaning (D1110) provided July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from January 18, 
2022, through May 23, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared and/or 
near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, 
including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral 
sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the infrared therapy services provided have not been met. Specifically, Medicare rules say that there is 
sufficient evidence to conclude that the use of infrared therapy devices and any related accessories is not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the infrared therapy 
(97026) provided from January 18, 2022, through May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the complete series of intraoral x-rays (D0210) provided on May 26, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this x-ray should be covered under your plan. 
The Plan denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the complete series of intraoral x-rays (D0210) 
provided on May 26, 2022.  
 
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 pay for revascularization, endovascular, open or percutaneous, 
tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in 
addition to code for primary procedure) (37232) provided May 25, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that you would like to submit an appeal for 
procedure code 37232. The Plan denied your request. The Plan says the records do not support service 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. 
 
In this case, the CPT Code Manual definition of code 37232 is revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List 
separately in addition to code for primary procedure). 
 
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 surgical procedure. Our reviewer says that CPT code 
37232 is not supported in the medical records. Our reviewer found the procedure report describes intervention 
in multiple vessels with single intervention. Operative report documents: under real-time ultrasound guidance, 
the other right anterior tibial was evaluated and determined patent and an appropriate potential access site. The 
vessel was then cannulated with concurrent real-time ultrasound visualization of access with a 21-gauge needle. 
Based on the angiographic images and evaluation noted above the decision to intervene in the right popliteal 
artery was made with atherectomy balloon angioplasty. 5mm balloon angioplasty. Tibial artery was made with 
atherectomy balloon angioplasty 2.5mm distally, 3mm mid and proximal, 4mm at origin for resistant stenosis 
mm balloon angioplasty. Based on the angiographic images and evaluation noted above the decision to 
intervene in the right tibioperoneal trunk was made with balloon angioplasty 4mm balloon angioplasty. All 
wires and sheath were removed and accounted for. In this case, per CPT guidelines for Endovascular 
revascularization (Open or percutaneous, transcatheter)." If a lesion extends across the margins of one vessel 
vascular territory into another, but can be opened with a single therapy, this intervention should be reported 
with a single code despite treating more than one vessel and/or vascular territory. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for revascularization, endovascular, open or percutaneous, tibial/peroneal artery, 
unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary 
procedure) (37232) provided May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a metal crown (D2751) for tooth #8, #9, and #11. 
 
You asked the Plan to pre-approve the dental services. You say that the dental procedures are necessary. The 
Plan denied your request. The Plan says the x-rays show a crown is not needed to fix the enrollee's tooth. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the documentation provided was not sufficient to meet the criteria for coverage for crown restorations. Our 
physician reviewer found that the documentation provided was not sufficient to determine the need for crown 
restorations (D2751) for teeth #8, #9 and #11. 
 
  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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a metal crown (D2751) for tooth #8, #9, and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9279 billed for date of service January 1, 
2021. 
 You asked the Plan to pay for procedure code A9279. You say that the enrollee has obstructive sleep apnea. 
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 A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code A9279 billed for date of service January 1, 2021.