Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services provided on March 4, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the code 
is not supported in the documentation. 
 
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 29827 is arthroscopy, shoulder, surgical; with rotator cuff 
repair. We find that CPT code 29827-22-LT is supported in the medical record. Specifically, the records show 
that a double row rotator cuff repair was provided. Based on this information, we decided that Medicare rules 
for coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the 
surgery services provided on March 4, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete mandibular denture (indirect) (D5751) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never advised that the Plan only 
covers one of the relines. 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 May 24, 2022. Therefore, 
we decided that the Plan does not have to pay for a reline complete mandibular denture (indirect) (D5751) 
provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330), 2D oral/facial photographic 
images (D0350), and an immediate mandibular denture (D5140) provided on October 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says 2D oral/facial photographic images (D0350) are not covered by 
your dental benefits. The Plan also says that your dental allowance has been met. 
 
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 your annual dental allowance has been met. 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 when the 
dental allowance has been met. Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330), 2D oral/facial photographic images (D0350), and an immediate mandibular denture (D5140) 
provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration for bone grafting, spine 
surgery only, through separate skin or fascial incision to line (20939). 
 
You asked the Plan to pre-approve the bone marrow aspiration. You say that the enrollee has exhausted non-
operative treatments regarding physical therapy, medications, activity restrictions and injections as well as 
chiropractic treatments. The Plan denied your request. The Plan says the Plan does not cover the use of bone 
marrow aspirate for this procedure. The clinical value and effectiveness of bone marrow aspirate in the setting 
of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the bone marrow aspiration for bone grafting, spine surgery only, through separate skin or 
fascial incision to line (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentures (CPT code(s): D5110 and D5120). 
 
You asked the Plan to pre-approve the dentures. You say that the dentures do not work because a lot of the 
denture glue has to be used. The Plan denied your request. The Plan says you exhausted your benefit frequency 
limit. 
 
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. 
 
Review of the file shows that you received dentures (CPT code(s): D5110 and D5120) on April 1, 2022. The 
office advised that you have not contacted them to report any issues with your current dentures. Please contact 
their office to discuss the issues that you are experiencing. Your 2022 EOC states complete dentures (upper and 
lower) (one (1) upper complete and 1 lower complete denture every five (5) years, including routine post-
delivery care) or Partial dentures (upper and lower) (1 upper and/or 1 lower partial denture every 5 years, 
including routine post-delivery care). Therefore, we decided that the Plan does not have to pre-approve the 
dentures (CPT code(s): D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by an out-of-network provider on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. 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 a comprehensive oral evaluation (D0150) and intraoral imaging (D0210) provided by an out-of-
network provider on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 16, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not 
separately payable. 
 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant/abutment supported denture (D6113) provided on 
June 9, 2022. 
 
You asked the Plan to pay for implant/abutment supported denture (D6113). You say that you would like the 
Plan to help pay for the dental service. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
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 implant/abutment 
supported denture (D6113) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for implant/abutment supported denture (D6113) provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 6, 2022, billed with 
codes 81225, 81226, 81227, 81401, 81231, 81291, 81335, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 
January 6, 2022, billed with codes 81225, 81226, 81227, 81401, 81231, 81291, 81335, and 81328.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with doppler 
(93306). 
 
You asked the Plan to pre-approve a TTE with doppler. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 TTE with doppler. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollees pre-test probability for an abnormal test is low and there is no 
documentation that the electrocardiogram shows an uninterpretable pattern. There is no evidence provided that 
would support the need for stress echocardiography. In summary, there is insufficient documentation to support 
the medical necessity for the requested stress echocardiography in this enrollees 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 TTE with doppler have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transthoracic echocardiogram (TTE) with doppler (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99051 and 97598 billed for date of service 
March 13, 2022. 
 
You asked the Plan to pay for procedure codes 99051 and 97598. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says procedure code 99051 is 
considered bundled and not separately payable and procedure code 97598 is an add-on code that has not been 
billed with an appropriate primary procedure code. 
 
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 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Additionally, we have confirmed that code 97598 is an add-on 
code and has not been billed with an appropriate primary procedure code. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99051 and 97598 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99051 and 97598 billed for date of service 
March 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on August 17, 
2021. 
 
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the billed service is not supported in the records 
provided. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress note for August 17, 2021 does not note how much time was 
spent providing services to the enrollee. As such, the provided documentation does not support the billing of 
code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) 
provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), double upright, thigh and calf, 
with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with 
or without varus/valgus adjustment, prefabricated, off-the shelf (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that medical records are attached to show medical 
necessity. The Plan denied your request. The Plan says the enrollee's request is not medically necessary 
because records show she does not have instability in her left knee. 
 
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 knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the knee brace is covered if the enrollee has had recent injury to or a surgical procedure on the 
knee(s). The L1845 can also be covered for an enrollee who is ambulatory and has knee instability documented 
with an objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). The 
documentation does not reveal objective physical exam evidence of knee instability. There is no evidence of 
recent injury or surgery to the knees. The enrollee is documented to be ambulatory however the criteria for the 
requested knee orthosis is not medically necessary and exceeds her needs. Medicare does not pay for any items 
or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension 
joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 
prefabricated, off-the shelf (L1852).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on April 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81455 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81455) provided on April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no need to repeat 
diagnostic blocks. The request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on April 29, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 office visit 
rendered on April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Seatara wheelable portable shower/commode (CPT 
code E0163). 
 
You asked the Plan to pre-approve the item. You say that you are bedridden, and wheelchair bound. You state 
that you are not able to go to the bathroom because you do not have the chair. The Plan denied your request. 
The Plan says a standard commode (CPT code E0163) was approved; however, you were asking for a brand 
specific commode chair that the durable medical equipment (DME) provider does not carry and is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
Review of the file shows that a standard commode chair is approved by the Plan, but the Seatara commode 
chair is not a standard shower chair or commode chair, but rather a wheel-able portable chair that goes over the 
toilet and can go into the shower. The brand you are requesting exceeds what Medicare covers in that it can be 
used as a shower chair, which is not covered by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the Seatara wheelable portable shower/commode (CPT code E0163).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve service dog support. 
 
You asked the Plan to pre-approve service dog support. You say that due to medical issues, you need the 
support of a service dog. The Plan denied your request. The Plan says they requested medical records from 
provider, no medical records were received. Therefore, they are unable to approve the request. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of service dog support. The Plan 
requested medical records from your provider but did not receive any, and without medical records we cannot 
determine whether you meet the criteria for a service dog. You should re-submit your request to the Plan with 
supporting medical records. Therefore, we decided that the Plan does not have to pre-approve service dog 
support.