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

We decided that the Plan does not have to pre-approve microsurgical techniques requiring an operating 
microscope (69990). 
 
You asked the Plan to pre-approve microsurgical techniques requiring an operating microscope. You say that 
the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that microsurgical techniques requiring the use of 
operating microscopes may be paid separately only when submitted with specified CPT codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of microsurgical techniques requiring an operating microscope have not been met. Specifically, the 
case record does not support that the service indicated by the CPT code 69990 will, in this case, be used with a 
service corresponding to a code specified in the rules. Therefore, we decided that the Plan does not have to pre-
approve microsurgical techniques requiring an operating microscope (69990).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met. Our physician 
reviewer found the enrollee has a right rotator cuff tear arthropathy and right shoulder osteoarthritis. The Plan 
has approved a reverse shoulder arthroplasty, which is not on the inpatient-only list. He is medically stable and 
has clearance for the procedure. The records do not support that the enrollee will require a greater than two 
midnight inpatient hospital stay for the planned procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to lower the copayment for an outpatient clinic visit (G0463) provided on 
September 16, 2022. 
 
You asked the Plan to lower the copayment for an outpatient clinic visit. You say that you were not admitted to 
the hospital for these wound care appointments. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $20 copayment for wound care or for provider and 
professional services provided in a specialist office.  
 
The Plan says you must pay $123.72 for an outpatient clinic visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $20 copayment for an outpatient clinic visit. Therefore, we decided that the 
Plan has to lower the copayment for an outpatient clinic visit (G0463) provided on September 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
May 13, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please process the claim for this patient with 
this information. The Plan denied your request. The Plan says the documentation does not support an additional 
test outside of BRCA (breast cancer gene) testing. 
 
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 81479 is unlisted molecular pathology 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 laboratory service. Our reviewer says that the Medicare criteria for coverage were not met. Our reviewer found CPT code 81479 is not supported by the documentation 
submitted. There are no results for unlisted molecular pathology testing. The only test results in the record are 
for approved code 81162. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for unlisted molecular pathology procedure (81479) provided May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on September 6, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IGRT (CPT code 77014). 
 
You asked the Plan to pay for the service. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the doctor's reasons for offering the service aren't medically necessary and there is 
no medical evidence the special radiation guidance is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the service have been met. Medical 
records were not provider; therefore, there is no medical evidence the special radiation guidance is needed. 
Therefore, we decided that the Plan does not have to pay for IGRT (CPT code 77014).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 88377. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88377 is bundled into payment for codes 81270, 
81339, 81219, and 81403. 
 
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 88377 
is a column II code to column I codes 81270, 81339, 81219 and 81403. 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 88377 billed for date of 
service May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you are requesting the transit kit so 
that you can take your wheelchair to your medical appointments. The Plan denied your request. The Plan says 
the transit kit is used to strap the wheelchair to a vehicle to travel outside the home. You do not meet criteria 
for approval of this 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 transit kit (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture provided on November 18, 2021, 
to December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 dental benefit maximum allowance 
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 Plan's 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 November 18, 2021. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture provided on November 
18, 2021, to December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the records provided support the need 
for the service which remains in dispute. The Plan denied your request. The Plan says medical studies haven't 
proven that a bone marrow aspirate is helpful for treatment of the enrollee's health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed.  
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
January 4, 2021, through January 6, 2021. 
 
You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital care provided 
was medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee did not meet 
medical necessity criteria for coverage of the services provided. 
 
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 pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted to the acute inpatient psychiatric hospital on December 31, 2020 with Major 
Depressive Disorder, Single Episode, Unspecified. Based upon the review of the records provided, it was not 
expected that this enrollee would improve in a reasonable period of time beyond the dates in question as he was 
not showing any dangerousness to self or others, auditory or visual hallucinations, and was without aggressive 
behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or 
abnormal behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. 
This enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a 
danger to himself or others, did not have any delusions, or auditory and visual hallucinations. It did not appear 
that active treatment was taking place beyond the dates 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 were 
for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a physician. Based 
upon the review of the records provided, this enrollee did not meet the criteria for coverage of the acute 
inpatient mental health treatment beyond the dates in question and could have been treated in a lesser restrictive 
setting. 
 
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 pay for the acute inpatient psychiatric hospital care provided from January 4, 2021, through January 6, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedures listed under CPT codes: 
23472, 23430, and 23585, are not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient 
Only List. The Plan states the procedure is currently approved as an ambulatory procedure and there is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The 
Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient 
level of care can be performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the review has determined that the inpatient hospital care is not necessary 
for the surgical procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) and 
electronic connection between wheelchair controller and 2 or more power seating motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee meets all necessary 
Medicare criteria coverage for all requested codes. The Plan denied your request. The Plan says although there 
are three requested power options, there is not a medical need to control these power options through the 
joystick. 
 
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. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left hemiplegia. The record is inconsistent in describing right upper 
body strength. The physician references left sided weakness and did not specifically record upper body 
strength. No right upper body impairments identified. The enrollee has adequate strength to manage standard 
power switches on a power wheelchair. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) harness (E2313) and electronic connection 
between wheelchair controller and 2 or more power seating motors (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not able to walk independently. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
may need physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 10, 
2022.  You asked the Plan to pay for procedure code 99100. You say that you are appealing the claim with medical 
records to process the claim for payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal guard  hard appliance, partial arch (D9946), 
gingival irrigation  per quadrant; lower left and lower right quadrant (D4921), and bone replacement graft for 
ridge preservation - per site (D7953) Tooth #3. 
 
You asked the Plan to pre-approve dental services billed under codes D9946, D4921 x2, D7953 and D5820. 
You say that the occlusal guard is medically necessary. The Plan denied your request. The Plan says 
documentation is insufficient to show that D9946 is needed. 
 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. This benefit includes occlusal 
guard  hard appliance, partial arch (D9946). Some covered supplemental dental services require prior 
authorization. This benefit includes only those items and services specifically listed in your Plan contract. 
Gingival irrigation  per quadrant; lower left and lower right quadrant (D4921), and bone replacement graft for 
ridge preservation - per site (D7953) are not covered under the Plans dental benefits. 
 
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 dental service billed under code D9946. 
Our physician reviewer found the documentation indicates extractions and restoration were done to eliminate 
and restore the teeth affected and the placement of a maxillary removable partial denture has been approved for 
coverage. It does not appear that an occlusal guard would be necessary. 
 
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 dental services billed under codes D9946 has not been met. The requested 
D4921 and D7953 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve occlusal guard  hard appliance, partial arch (D9946), gingival irrigation  per quadrant; 
lower left and lower right quadrant (D4921), and bone replacement graft for ridge preservation - per site 
(D7953) Tooth #3.