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

 
We decided that the Plan does not have to pay for blood bank physician services (86077) provided on August 
31, 2021. 
 
You asked the Plan to pay for blood bank physician services. You say that you would like this claim 
reprocessed based on the level of service provided. The Plan denied your request. The Plan says the claim has 
denied correctly based on Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for blood 
bank physician services (86077) provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210) and intraoral - periapical first radiographic image (D0220) provided November 18, 2021. 
 
You asked the Plan to provide additional payment for the tooth extraction and intraoral x-ray. You say that you 
would like the claim paid. The Plan denied your request. The Plan says the tooth extraction was covered 
correctly, and you have exceeded frequency limit for the intraoral x-ray. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the tooth 
extraction with 50% coinsurance and intraoral x-rays are covered once per calendar year. 
 
We looked at the file and Medicare rules. You have been asked to pay $62.50 ($125 allowed amount x 50% 
coinsurance = $62.50) for the tooth extraction. The Plan provided documentation showing that you previously 
had an intraoral x-ray covered on November 1, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the intraoral x-ray has been exceeded. Therefore, we decided that the Plan does 
not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and intraoral - 
periapical first radiographic image (D0220) provided November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and related components (L5828, 
L5845, L5848, L5850, L5856). 
 
You asked the Plan to pre-approve a microprocessor knee and related components. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules have not been met for the requested items. 
 
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 a microprocessor knee and related 
components. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that in this case, the documentation doesn't indicate why the 
approved mechanical K3 knee isn't sufficient for the members ambulatory needs. There is no documentation to 
indicate the microprocessor knee is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor knee and related components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a microprocessor knee and related components (L5828, 
L5845, L5848, L5850, L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had to find a new dentist. You say that your 
previous dentist no longer accepted your insurance. You say that the exam was necessary as you were a new 
patient. You also say that you feel this service should be covered. The Plan denied your request. The Plan says 
the frequency limit has been exceeded. 
 
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 and 1 oral exam is covered per year, the 
frequency limit has been exceeded. The record shows that the Plan paid for an oral exam that you received on 
May 18, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), the cone beam computed 
tomography (CT) capture and interpretation (D0364), and pulp vitality test (D0460) provided on April 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider contacted the plan to get approval 
for the services. You say that all but one was approved. You say that it ends up that one office location is in 
network and the other is not. You also say that you have a lot on your plate right now. The Plan denied your 
request. The Plan says consultation, cone beam CT, and pulp vitality test are not covered services.  
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 consultation, cone beam CT, and 
pulp vitality test are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the consultation (D9310), the cone beam computed tomography (CT) capture and interpretation 
(D0364), and pulp vitality test (D0460) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of two surfaces (D2331), resin-
based composite of three surfaces (D2393), and resin-based composite of four or more surfaces (D2394) 
provided on March 29, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the resin-based composites. You say that you have been going to this dentist for 
20 years. You also say that you did not know that you had to ask if he was in-network for Medicare dentists, 
and had no idea that he opted out of Medicare until after your claim was denied. The Plan denied your request. 
The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan 
also says that the treating provider opted out of Medicare effective January 26, 2016, to January 26, 2024, and 
the Plan was advised that patients were informed verbally that this provider had opted out of Medicare. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite of two surfaces (D2331), resin-based composite of 
three surfaces (D2393), and resin-based composite of four or more surfaces (D2394) provided on March 29, 
2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional prosthetic equipment, including K3 
ambulation components. 
 
You asked the Plan to pre-approve additional prosthetic equipment. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the prosthetic equipment is subject to the criteria 
listed 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 additional prosthetic equipment. Our 
reviewer says that the requested equipment is not medically reasonable and necessary. Our physician reviewer 
found that the enrollee is a 61-year-old man who underwent a left above-knee amputation 15 years ago due to 
trauma. It is documented that the enrollee has not utilized a prosthesis for the last 4 - 5 years due to severe 
depression and health issues. The enrollee is currently using a walker and wheelchair. It is documented that the 
enrollee is unable to consistently use crutches because of pain to the hands and arms, and consequently has 
been confined to a wheelchair which has led to weight gain and mental health concerns. The orthotist notes on 
November 2, 2021, that he explained to the enrollee that he "must have a basic knee to get started with 
ambulating again so that we can determine if he is qualified for" a high-level microprocessor knee. In this case, 
the documentation is insufficient to support that the enrollee has the ability or potential for ambulation with 
variable cadence, typical of a community ambulator who has the ability to traverse most environmental barriers 
and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple 
locomotion. In addition, the equipment that is requested is not covered as it is not designed for the current 
prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional prosthetic equipment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional prosthetic equipment, including K3 ambulation components.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D9420, D7140) provided November 3, 2021 
to November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are non-covered. 
 
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. Services obtained out-of-network are non-covered. Therefore, we 
decided that the Plan does not have to pay for dental services (D9420, D7140) provided November 3, 2021 to 
November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 1, 2021. 
 
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 there is no additional documentation supporting additional studies which were billed and remain 
denied. 
 
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: 
 
CPT 70450: 
 
Computed tomography, head or brain; without contrast material 
 
CPT 71045: 
 
Radiologic examination, chest; single view 
 
CPT 74177: 
 
Computed tomography, abdomen and pelvis; with contrast material(s) 
 
CPT 76705: 
 
Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) 
 
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 there is no evidence of a second 
computed tomography (CT) of the brain without contrast (70450), no evidence of a second chest x-ray (71045), 
or evidence of a second right upper quadrant ultrasound (76705). Additionally, there is no record of any CT of 
the abdomen and pelvis (74177) on this date of service. 
 
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 additional imaging services provided to the enrollee on October 1, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required for teeth 
#5,7, and 8. 
 
You asked the Plan to pre-approve core buildup, including any pins when required for teeth #5,7, and 8. 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. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of core buildup, including any pins when required for teeth #5,7, and 8 have not been met. 
Specifically, medical records were not provided. Without this documentation, medical necessity is not able to 
be established. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any 
pins when required for teeth #5,7, and 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic exam (D0120), radiographic images (x-rays) 
(D0220, D0230), bitewing x-rays (D0274), and cleaning (D1110), provided on November 10, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the annual maximum has already been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, the records indicate you have already received the 
maximum allowance for routine dental service and are responsible for any cost over.  Therefore, we decided that the Plan does not have to pay for the periodic exam (D0120), radiographic images (x-rays) (D0220, D0230), bitewing x-rays (D0274), and cleaning (D1110), provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty (D7310), provided on October 18, 2021. 
 
You asked the Plan to pay for the alveoloplasty. You say that the service should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
alveoloplasty (D7310), provided on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management 
services (99239) provided on October 27, 2020. 
 
You asked the Plan to pay for the discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
does not support that more than 30 minutes of hospital discharge day management services were rendered. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate that amount of time spent providing the hospital discharge day management services. Based 
on this information, we decided that Medicare rules for coverage of the discharge day management services 
have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of 
hospital discharge day management services (99239) provided on October 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 16, 2021. 
 
You asked the Plan to pay for physician's services. You say that the patient was not enrolled in hospice on this 
date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 25, 
2021. 
 
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 claim does not meet proper coding standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Proteor Symphony Knee (L5814, L5845, L5848, 
L5850) and Rush HiPro foot (L5981) for use with an approved prosthesis. 
 
You asked the Plan to pre-approve the specific knee and foot prosthetic components. You say that it is felt that 
the enrollee has the functional potential to require the requested prosthetic components. The Plan denied your 
request. The Plan says the requested knee and foot exceed the enrollee's needs and ability. The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities as described 
in the Medicare rules section of this decision.  
 
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 specific knee and foot prosthetic 
components. Our reviewer says that the documentation does not support that the requested components are 
medically necessary for the enrollee. Our physician reviewer found the physician documentation does not 
support that the patient is a K3 ambulator. The patient has multiple comorbidities including sciatica, 
rheumatoid and osteoarthritis, hip contracture on the left, cardiac disease, uncontrolled diabetes, history of 
stroke who currently uses a walker in the home and wheelchair out of the home.  
 
The documentation does not support that the patient requires the advanced foot with features that do not serve a 
primary medical need (i.e., waterproof for salt water and engineered for the most aggressive terrain). Similarly, 
the requested K3 Symphony knee exceeds the patient's medical need. The features of this knee include a 6 Bar 
polycentric structure that provides an extremely high level of stability during stance phase and an innovative 
mechanical sensor, the p-MRS system, which automatically detects gait status and controls the stability of the 
knee joint accordingly. The documentation from the physician does not support that the patient is a K3 
ambulator and the requested Symphony knee has complex technological features which appear to exceed the 
patient's functional/medical 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 the specific knee and foot prosthetic components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Proteor Symphony Knee (L5814, L5845, L5848, 
L5850) and Rush HiPro foot (L5981) for use with an approved prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (D9222) and extractions (D7140, D7210), 
provided on October 7, 2021. 
 
You asked the Plan to pay for the anesthesia and extractions. You say that the services should be covered. The 
Plan denied your request. The Plan says when seeing an out of network dentist the member is responsible for 
the difference between the Plan's allowed amount and that dentist's fees. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
anesthesia (D9222) and extractions (D7140, D7210), provided on October 7, 2021.