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

 
We decided that the Plan does not have to pay for the office visit provided on October 04, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were not aware that the provider was not in-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup, pontic, retainer crown (D6740, D2950, 
D6245) provided on December 12, 2022. 
 
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 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 pay for a core 
buildup, pontic, retainer crown (D6740, D2950, D6245) provided on December 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy for tributary veins. 
 
You asked the Plan to pre-approve the requested sclerotherapy. You say that criteria are met, and the enrollee 
continues with symptoms despite conservative care The Plan denied your request. The Plan says the criteria are 
not met for sclerotherapy at this time. 
 
The Plan follows Medicare rules. Medicare rules say that tributary treatment is not covered until saphenous 
reflux is successfully eliminated and symptoms persist. 
 
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 requested sclerotherapy. Our 
reviewer says that the requested sclerotherapy is not shown to be reasonable and necessary in this case. Our 
physician reviewer found for tributary treatment such as sclerotherapy to be considered medically necessary per coverage criteria, there needs to be persistent significant symptoms following successful treatment of 
truncal (saphenous) reflux with these symptoms existing more than 6 weeks after the reflux was treated and 
despite conservative efforts. Additionally, the veins to be treated need to be at least 4 mm in diameter.  
 
As the enrollee has not yet undergone saphenous vein reflux treatment, the above criteria have not been met. 
The health plan does not provide for simultaneous saphenous reflux treatment and tributary treatment. A 
rationale for this is that many patients experience satisfactory relief with the truncal intervention alone. This is 
supported by the LCD criteria and medical guidelines. 
 
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 requested sclerotherapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sclerotherapy for tributary veins.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion, any size 
(E2609) and a custom fabricated wheelchair back cushion, any size, including any type mounting hardware 
(E2617). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested cushions are medically 
necessary. The Plan denied your request. The Plan says the records sent do not show prefabricated seating will 
meet your needs. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have scoliosis, kyphosis, pelvic tilt and is stated to need custom seating and 
back. You have COPD, protein calorie nutrition, epilepsy, depression, anxiety, and severe postural deformities 
from CP. You have a reduced ability to weight shift. The requested accessories exceed your needs as the 
occupational therapy (OT) evaluation does not support that you require custom cushions for the back and seat 
due to severe deformities. The evaluation states your seating needs can be met with a prefabricated seating 
system. Policy Article A52505 criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a custom fabricated wheelchair seat cushion, any size (E2609) and a custom 
fabricated wheelchair back cushion, any size, including any type mounting hardware (E2617).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates for service February 3, 
2022, to February 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were provided for emergency care. 
The Plan denied your request. The Plan says the records do not support the billed code. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem.  
 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 the billed services. Our reviewer found that 
the provided daily notes do not contain a detailed interval history or evidence of high-complexity medical 
decision making.  As such, the billing of CPT 99233 is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for dates for service February 3, 2022, to February 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 3 hours a day, 5 days a week of home 
health aide services. 
 
You asked the Plan to pre-approve the additional home health aide hours. You say that you forget things, get 
very dizzy when you walk, and also need help bathing to avoid falls. You also say that you need assistance to 
wash your clothes and preparation of your breakfast. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an additional 3 hours a day, 5 days a week of home health aide services have not been met. 
Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we 
decided that the Plan does not have to pre-approve an additional 3 hours a day, 5 days a week of home health 
aide services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like this to be 
approved for your nutritional knowledge and overall health. You also say that you need a nutritional plan. The 
Plan denied your request. The Plan says the medical records from your primary care physician show you do not 
have a diagnosis of renal disease or diabetes. The Plan also says the requested medical nutrition therapy visit is 
not approved at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
 
 
 
 Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on December 13, 2022. 
 
You asked the Plan to pay for an outpatient surgery. You say that the coding was correct. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient surgery 
provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one custom fabricated abutment and one abutment 
supported crown. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 items or services was exhausted on authorization number 
A0230329000002. Therefore, we decided that the Plan does not have to pre-approve one custom fabricated 
abutment and one abutment supported crown.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen, oxygen supplies and disposable supplies 
provided on November 10, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you would like the Plan to reconsider the 
initial denial. The Plan denied your request. The Plan says the supplies service are non-covered benefits by the 
health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance transport, oxygen, oxygen supplies and disposable 
supplies provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99223. We decided that the Plan does not have to pay 
for procedure code 99497. 
 
You asked the Plan to pay for procedure codes 99497 and 99223 billed for June 22, 2022. You say that you 
disagree with the denial. The Plan says that 99497 is not supported and 99223 was billed on the same date of 
service as an outpatient claim. 
 
We decided that the Plan has to pay for .  
 
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. The Plan states that initial hospital care code 99223 is not separately payable 
because it was billed on the same date of service as outpatient emergency room (ER) code 99283. The 
Medicare rules clearly state that inpatient hospital care is paid if the patient is seen in the emergency room and 
then admitted to the hospital. It is the ER code that is not separately paid. The Plan has provided no 
documentation or binding Medicare rules to support that code 99223 is not payable as billed. Therefore, we 
decided that the Plan has to pay for procedure code 99223 billed for June 22, 2022. 
 
We also decided that the Plan does not have to pay for procedure code 99497. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of 
the time spent providing services. 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 procedure code 
99497 billed for June 22, 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 procedure codes 88341 and 88342 billed for date of service 
October 17, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88342. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 88341 and 88342 is bundled into 
payment for code 88360. 
 
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 codes 
88341 and 88342 are column II codes to column I code 88360. 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 codes 88341 and 88342 billed for 
date of service October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OsteoCell allograft and a bone marrow aspiration. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says studies 
have not proven the procedures helpful for treatment. 
 
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 requested services. Our physician 
reviewer found that the Plan approved the lumbar laminectomy and spinal fusion (L4-5 XLIF and L3-5 
posterior lumbar fusion). 

However, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested OsteoCell allograft, in this case, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an OsteoCell allograft and a bone marrow aspiration.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 22, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment for teeth #8 and 13 (D6057) 
and abutment supported porcelain/ceramic crown for teeth # 13 and 28 (D6058). 
 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you were already approved for 2 implants in the same visit exhausting your benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutment for teeth #8 and 13 (D6057) and abutment supported 
porcelain/ceramic crown for teeth # 13 and 28 (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 30, 2022. 
 
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 documents do not support this level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 that the records did not support a 
comprehensive history and medical decision making of high complexity. 
 
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 initial hospital care (procedure code 99223) rendered on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backrest and side guards. 
 
You asked the Plan to pre-approve a backrest and side guards. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested items are not a covered benefit.  

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 backrest 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. The requested 
side guards 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 backrest and side guards.