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

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the enrollee requires a 
motorized wheelchair with a power lift and power elevate function for a lifetime to promote functional 
independence. This will also improve posture and comfort. The power elevate function is critical for preventing 
falls. The elevate function will allow her to be able to transfer more safely by using her extensor spasticity at a 
safer height when transferring from sit to stand solely relying on her weak and ataxic upper limbs. The Plan 
denied your request. The Plan says the requested item is not a covered benefit and considered not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 11, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 11, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
11, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of October 11, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond October 11, 2022, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 11, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 11, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided by a participating provider on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought these services did not apply to your 
calendar year maximum. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided by a participating provider on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #7 and 11 (D6750) and pontics 
on tooth #8 and 9 (D6210). 
 
You asked the Plan to pre-approve crowns and pontics. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the crowns that support the current fixed bridge appear to be in 
good condition. 
 
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 crowns and 
pontics 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 and pontics. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that tooth #7 and 11 do not have any 
significant areas of breakdown or existing restoration. The Plan would not consider these teeth for abutments, 
and therefore not allowed for the requested bridge. 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 and pontics have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns on tooth #7 and 11 (D6750) and pontics on tooth #8 and 9 (D6210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation (D9222), surgical removal of an implant body 
(D6100), the bone replacement graft for ridge preservation (D7953), and the comprehensive oral evaluation 
(D0150) provided by an out-of-network provider on March 24, 2022. 
 
You asked the Plan to pay for deep sedation (D9222), surgical removal of an implant body (D6100), the bone 
replacement graft for ridge preservation (D7953), and the comprehensive oral evaluation (D0150). You say that 
the dentist was able to provider surgery services on the day you saw him since this was an emergency. You say 
you did not know the dentist was out-of-network. The Plan denied your request. The Plan says the services are 
not covered 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 deep sedation (D9222), surgical 
removal of an implant body (D6100), and the bone replacement graft for ridge preservation (D7953) are not 
among those covered under this benefit. Also, the comprehensive oral evaluation (D0150) is not covered under 
this benefit when received from an out-of-network provider. The record shows the provider was out-of-
network. 
 
Therefore, we decided that the Plan does not have to pay for deep sedation (D9222), surgical removal of an 
implant body (D6100), the bone replacement graft for ridge preservation (D7953), and the comprehensive oral 
evaluation (D0150) provided by an out-of-network provider on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140) and deep sedation (D9222 and 
D9223) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an 
extraction (D7140) and deep sedation (D9222 and D9223) provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 77003. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says payment for code 77003 is bundled into 
payment for code 22513. 
 
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 77003 
is a column II code to column I code 22513. 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 77003 billed for date of service April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance (G6001) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that neither NCCN nor other guidelines recommend US imaging for 
staging, diagnosis, or to assess treatment response. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Using ultrasound on 
a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations 
and/or Image-guided radiation therapy (IGRT) for a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these devices in general) is not necessary. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasonic guidance (G6001) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on June 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services rendered on January 
12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all diagnosis codes not listed as those supporting 
medical necessity do not support medical necessity of procedure codes 95870 and 95865. 
 
We looked at the file and Medicare rules. The file shows that procedure codes 95870 and 95865 were not billed 
with a diagnosis code listed as supporting medical necessity in the Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for the needle electromyography services rendered on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5213)
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your benefit for the requested item 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan contract states that one complete upper denture is covered 
every five years. The Plan has stated that you have exhausted the allowable benefit for the requested item as a 
complete upper denture was previously provided to you on October 4, 2021. However, we requested proof of 
payment for this item issued but the Plan has not provided the requested information. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-
approve a complete upper denture (D5110).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant removal on tooth #30 (D6100). 
 
You asked the Plan to pay for implant removal. You say that this service is medically necessary. The Plan 
denied your request. The Plan says implant removal (D6100) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
removal on tooth #30 (D6100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics expandable controller (E2377) 
harness (E2313) electronic connection between wheelchair controller and two or more power seating system 
motors (E2311) armrest bracket (K0108) elbow pads (K0108) elbow support brackets (K0108) footplates 
(K0108) Q-logic 3 ex joystick (K0108) personal item hook (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and components. You say that the records support 
the necessity of the requested power wheelchair. The Plan denied your request. The Plan says the upgraded 
electronics are not medically necessary as the approved options come with their own switches. The armrests, 
armrest bracket, elbow pads, elbow supports, and footplates are included with the approved chair. The Q-logic 
3 ex joystick is already included with the requested expandable controller E2377. The personal item hook does 
not serve a medical purpose. 
 
 
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 upgraded electronics and 
components. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that the upgraded electronics and other accessories at issue in this case meet all Medicare 
criteria for medically reasonable and necessary for the patient per Local Coverage Article - Wheelchair 
Options/Accessories - Policy Article A52504. Provided records document that the enrollee has 4-/5 right upper 
extremity strength and is able to use his upper extremity for "some activities of daily living" and for use of a 
urinal thus indicating he has adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches. The armrests, armrest bracket, elbow pads, elbow support and footplate are 
included with the approved chair. The Q-Logic 3 EX joystick is already included with the requested 
expandable controller E2377 and the personal item hook does not serve a medical purpose. 
 
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 upgraded electronics and components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve upgraded electronics expandable controller (E2377) harness 
(E2313) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) armrest bracket (K0108) elbow pads (K0108) elbow support brackets (K0108) footplates (K0108) Q-
logic 3 ex joystick (K0108) personal item hook (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2021 billed with 
codes 81286, 81407, 81408 and 81439. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 2, 2021 billed with codes 81286, 81407, 81408 and 81439.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the 
approved cover meets your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications. 
 
The file shows that protective outer surface covering, L5962, was requested. We looked at the file and 
Medicare rules. The records do not show that the enrollee has a need for protection against unusually harsh 
environmental situations. The records do not show that the approved cover, L5704, will not offer sufficient 
protection and weatherproofing for the enrollee.  Based on this information, we decided that Medicare rules for coverage of the requested item have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic (CT) angiography (CTA) of the chest (71275).

You asked the Plan to pre-approve a CTA of the chest. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says the requested CT angiography is not medically necessary in this case.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CTA of the chest. Our reviewer says that the requested service is not medically necessary according to Medicare guidelines. Our physician reviewer found while you had dyspnea, lower extremity deep vein thrombosis was diagnosed, and oral anticoagulation started. Thus, a chest CTA is not required. Clinical guidelines for the use of chest CTA have not been met based on review of the submitted clinical documentation. As a result, at this time chest CTA would not be considered medically reasonable and necessary in your clinical management.

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 CTA of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic (CT) angiography (CTA) of the chest (71275).