Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain fused to predominately base metal
on teeth #'s 19, 20, 26, 27 (D2751), the core build-up, including any pins when required on tooth #20 (D2950),
and the prefabricated post and core in addition to crown on tooth #26 (D2954).

You asked the Plan to pre-approve the crown - porcelain fused to predominately base metal on teeth #'s 19, 20,
26, 27 (D2751), the core build-up, including any pins when required on tooth #20 (D2950), and the
prefabricated post and core in addition to crown on tooth #26 (D2954).. You say that the enrollee needs post
and core on tooth #26 to build-up tooth structure. The enrollee needs a crown on tooth #19, 26, and 27 to
prevent future breakdown of teeth. The Plan denied your request. The Plan says the services are not medically
necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown -
porcelain fused to predominately base metal on teeth #'s 19, 20, 26, 27 (D2751), the core build-up, including
any pins when required on tooth #20 (D2950), and the prefabricated post and core in addition to crown on tooth
#26 (D2954). 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 the crown - porcelain fused to
predominately base metal on teeth #'s 19, 20, 26, 27 (D2751), the core build-up, including any pins when
required on tooth #20 (D2950), and the prefabricated post and core in addition to crown on tooth #26 (D2954)..
Our reviewer says that the dental services are not medically necessary. Our physician reviewer found that the
documentation provided indicates that tooth #20 is broken down beyond the point of restoration: caries extends
sub-osseous and the crown root ration would be inadequate for long term success. The radiographs provided for
tooth #19 did not show the complete tooth therefore a determination of need for a crown restoration could not
be made. The radiographs are not adequate to determine need of the teeth indicated.

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 the crown - porcelain fused to predominately base metal on teeth #'s 19, 20, 26,
27 (D2751), the core build-up, including any pins when required on tooth #20 (D2950), and the prefabricated
post and core in addition to crown on tooth #26 (D2954). have not been met. Therefore, we decided that the
Plan does not have to pre-approve the crown - porcelain fused to predominately base metal on teeth #'s 19, 20,
26, 27 (D2751), the core build-up, including any pins when required on tooth #20 (D2950), and the
prefabricated post and core in addition to crown on tooth #26 (D2954).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan
denied your request. The Plan says the enrollee must try and fail Dysport or Xeomin first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Botox. Our reviewer says that the Plan's
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records
provided and the Medicare-approved major drug compendia there is no indication that the plan's required
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71275 billed for date of service July 27, 2022.

You asked the Plan to pay for procedure code 71275. You say that this service was medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 

In this case, the MUE for CPT code 71275 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 71275 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 71275 billed for date of service July 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested Prolia. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet criteria for the requested Prolia. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of Osteoporosis without pathological fracture. The Food and Drug Administration 
has stated that the requested drug is indicated for the enrollee's condition. The records provided are insufficient 
to establish that the requirements of the local coverage determination are satisfied. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 29823-AS-LT billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that guidelines allow the procedures to be performed 
and reimbursed when performed on the same shoulder. The Plan denied your request. The Plan says that the 
code is not supported in the documentation. 
 
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. 
 
We looked at the file and the rules. The case summary and appeal indicate that medical records were provided. 
The Plans review cites the operative report in their decision to deny services. However, medical records were 
not included in the case file. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
procedure code 29823-AS-LT billed for date of service February 24, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa.

You asked the Plan to pre-approve Gemtesa. You say that you have prescribed Gemtesa because the enrollee has failed therapy with Ditropan use and has a personal history of glaucoma and dementia which could worsen with Ditropan use. The Plan denied your request. The Plan says Gemtesa is a self-administered drug, and does not fall under Part B coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa. 

 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that you cannot leave the hospital without the
device, it is medically necessary. The Plan denied your request. The Plan says the request for a home
mechanical ventilator set in VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not
covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 home ventilator. Our reviewer says
that the service is not medically necessary. Our physician reviewer found you have severe COPD, with at least
2 hospitalizations with acute on chronic hypercarbic respiratory failure. The most recent admission was
accompanied by severe anemia and CHF exacerbation. You did not tolerate BiPAP in the hospital. It appears
that BiPAP has not been tried at home, and you are unwilling to use it. A home ventilator will have the same
interface issues. BiPAP can provide the AVAPS mode of support, and Medicare does not cover a home
ventilator when used as BiPAP.

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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning belt/safety belt/pelvic strap (E0978), an 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), an 
expandable controller harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the accessories are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
power options. 
 
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 the enrollee has multiple sclerosis and has very limited ambulation. He is able to use 
upper body to squat transfer. The enrollee has adequate upper body strength to manage standard switches on a 
power wheelchair. A seat belt is already included with the approved power wheelchair; therefore, the requested 
seatbelt is not covered. 
 
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 positioning belt/safety belt/pelvic strap (E0978), an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), an expandable controller 
harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
that the request is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that an expandable controller is necessary to accommodate the 
functions listed in the Medicare rules section of this letter. 
 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested components for a power wheelchair are 
medically reasonable and necessary in this case. Our physician reviewer found that the expandable controller 
with harness and electronic connection are necessary to operate the Group 3 power wheelchair base and the 
power tilt and recline and power elevating leg rests via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (2311) for a power wheelchair.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99497 and 99239 billed for date of service 
April 9, 2022, to April 10, 2022. 
 
You asked the Plan to pay for procedure codes 99497 and 99239. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99223. In addition, code 99239 is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent 
providing discharge care is not noted in the medical record. Without this information, a time-based code such 
as 99239 cannot be verified. Based on this information, we decided that Medicare rules for coverage of 99239 
have not been met. 
 
In addition, we have confirmed that code 99497 is a column II code to column I code 99223. 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 99497 
and 99239 billed for date of service April 9, 2022, to April 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 15271 provided on January 11, 2022. 
 
You asked the Plan to pay for procedure code 15271. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan based their denial rational on Local Coverage Article 
A57680, which is not in the correct jurisdiction for this case. We find that the Plan has not provided enough 
evidence to support the denial of payment for procedure code 15271 based on Medicare criteria. Therefore, we 
decided that the Plan has to pay for procedure code 15271 provided on January 11, 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 the drug testing provided to the enrollee on September 9, 2021.
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because only 15 drug classes were counter in the lab results submitted which does not support code G0483.
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 G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the test results submitted do not include more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided to the enrollee on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided to the enrollee on July 13, 2021.
You asked the Plan to pay for the x-ray services. You say that the professional reading must be billed separately from the technical charge. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed. We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on November 18, 2021. Comparison of the two claims shows these are exact duplicates.
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided to the enrollee on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided to the
enrollee on March 10, 2022.
You asked the Plan to pay for the acupuncture treatment. You say that you are requesting a reconsideration of
the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by
an unqualified provider.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the NPI provided on the claim form was for a nurse
practitioner and not a licensed acupuncturist. If services were provided by a licensed acupuncturist the claim
form should reflect the correct provider of services. Therefore, we decided that the Plan does not have to pay
for the acupuncture treatment (97810, 97811) provided to the enrollee on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0120) and interim partial denture (D5820) provided on December 17, 2021.
You asked the Plan to pay for the dental services. You say that the dental services should be covered. The Plan denied your request. The Plan says your benefit for the complete series of radiographic images has already been exhausted and the interim partial denture is not covered.
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 complete series of radiographic images was exhausted on date of service December 11, 2017.
The Plan does not cover interim partial dentures. Therefore, we decided that the Plan does not have to pay for the complete series of radiographic images (D0120) and interim partial denture (D5820) provided on December 17, 2021.