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

 
We decided that the Plan does not have to pre-approve the q-logic 2 joystick (CPT code K0108) and adjustable 
height, detachable armrest, complete assembly (E0973 x 2). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that the requested joystick module controller display is included with the requested controller. This cannot be requested 
separately. The armrests are included with the approved wheelchair. E0973 adjustable height arm rest, is listed 
under Column II, and E1007 power tilt and recline is listed under Column 1. Therefore, payment of E0973 is 
included in the requested E1007. A separate request for E0973 should be denied as unbundled. Therefore, we 
decided that the Plan does not have to pre-approve the q-logic 2 joystick (CPT code K0108) and adjustable 
height, detachable armrest, complete assembly (E0973 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5828, L5845, L5848, and 
L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the requested microprocessor knee is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested microprocessor 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 microprocessor knee. Our reviewer 
says that the enrollee does not meet criteria for the requested microprocessor knee. Our physician reviewer 
found the documentation indicates the member is a K3 functional ambulator and the health plan has authorized 
a K3 functional level mechanical knee and foot.  There is no documentation to indicate why a microprocessor 
knee is medically necessary. There is no indication she has failed the use of a mechanical knee. 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee (L5828, L5845, L5848, and L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup including any pins, when required (D2950) x3 
and intraoral - periapical each additional radiographic image (film) (D0230). 
 
You asked the Plan to pay for dental services. You say that you cannot afford to pay the bill for the services 
received. The Plan denied your request. The Plan says one service is not covered under your Plan and one is 
covered but limitations apply. 
 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. Core buildup including any 
pins, when required (D2950) is not covered under the Plans dental benefit. This benefit includes intraoral - 
periapical each additional radiographic image (film) (D0230)  one procedure code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core buildup including 
any pins, when required (D2950) x3 is not among those covered under this benefit. You had covered intraoral - 
periapical first radiographic image (D0220) on June 13, 2022. Therefore, this benefit was exhausted as of June 
13, 2022. Therefore, we decided that the Plan does not have to pay for core buildup including any pins, when 
required (D2950) x3 and intraoral - periapical each additional radiographic image (film) (D0230) provided on 
June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377), harness for upgrade to 
expandable controller (E2313) electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please see attached documentation 
for appeal. The Plan denied your request. The Plan says the upgraded electronics (expandable controller, 
harness and electronic connector) are 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 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 adequate upper extremity strength to manage standard switches for 
the power drives. 
 
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 for upgrade to expandable controller 
(E2313) electronic connection between wheelchair controller and 2 or more power seating system motors 
(E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture services coded 87150 provided on May 25, 2022. 
 
You asked the Plan to pay for the culture services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
 
 
 We find that CPT code 87150 is not supported in the medical record. Specifically, the documentation does not 
contain results to support organism culture and typing by nucleic acid probe. Based on this information, we 
decided that Medicare rules for coverage of the culture services have not been met. Therefore, we decided that 
the Plan does not have to pay for the culture services coded 87150 provided on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 21, 
2022, through May 6, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient hospital care provided was 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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that a request for payment was made for the inpatient hospital care provided from February 24, 
2022, through May 6, 2022. The Plan approved all but the last 15 days of inpatient care from April 21, 2022, 
through May 6, 2022. The enrollee has dementia with worsening sun downing behavior in the assisted living 
facility. She was noted to be alert and oriented x 1 and was diagnosed with a urinary tract infection and acute 
kidney injury. She was treated in the hospital with fluids, antibiotics, and Aripiprazole and Haldol as-needed. 
She was initially not stable enough to discharge back to the assisted living facility. However, from April 21, 
2022 to discharge on May 6, 2022, the enrollee was noted to not have any more outbursts, was not trying to get 
out of bed, and was generally pleasant without any behavioral issues. This would suggest that she would have 
been appropriate for a lower level of care until placement was determined and arranged. The enrollee was 
stable and was no longer expected to require inpatient services that would cross 2 midnights from April 21, 
2022 forward.  
 
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 hospital care provided from April 21, 2022, through May 6, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95912 and 95886 billed for date of service February 
15, 2022. 
 
You asked the Plan to pay for procedure codes 95912 and 95886. You say that these services are supported as 
billed. The Plan denied your request. The Plan says that these services are 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.  
 
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 procedure codes 95912 and 95886. Our reviewer says that 
these services were reported appropriately. Our reviewer found these services are supported in the medical 
records provided, and there are no bundling issues with either of these codes in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95912 and 95886 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 95912 and 95886 billed for date of service February 15, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010 and 97026 billed for date of service 
April 26, 2022. 
 
You asked the Plan to pay for procedure codes 97010 and 97026. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says procedure code 97010 is 
considered bundled and not separately payable. In addition, procedure code 97026 is for infrared therapy which 
is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that the use of infrared 
and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the 
treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic 
peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. We also find that code 97026 reports infrared therapy which is 
not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 97010 and 97026 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97010 and 97026 billed for date of service April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Med-Mizer bed. 
 
You asked the Plan to pre-approve the Med-Mizer bed. You say that the bed is necessary. The Plan denied your 
request. The Plan says the total electric bed with height adjustment feature is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the Med-Mizer bed have not been met. A Med-Mizer bed which 
has a hi-low feature (electric height adjustment feature) is for the convenience of the enrollee to transfer from 
the bed to the wheelchair. Therefore, we decided that the Plan does not have to pre-approve the Med-Mizer 
bed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve a CT scan. You say that the CT scan is medically necessary because of the 
enrollee's past medical history. The Plan denied your request. The Plan says the service is not considered 
reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
CT scan of the abdomen and pelvis is not reasonable or medically necessary. Our physician reviewer found that 
the CT scan is not necessary in this case as the prior carcinoma was located in the head/neck area and not in the 
abdomen/pelvic area and there was no finding on exam or history suggesting possible involvement of the 
carcinoma in the abdominal or pelvic area. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system addition (L5910) and an acrylic 
socket (L5629). 
 
You asked the Plan to pre-approve an alignable system addition and an acrylic socket. You say that these items 
are medically necessary. The Plan denied your request. The Plan says these items cannot be approved with the 
enrollee's prosthesis. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities  
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 alignable system addition and an 
acrylic socket. Our reviewer says that the requested components are not medically necessary. Our physician 
reviewer found the alignable system exceeds the enrollee's medical need and the acrylic socket is considered 
not reasonable and necessary when provided with a knee prosthesis. 
 
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 alignable system addition and an acrylic socket have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an alignable system addition (L5910) and an 
acrylic socket (L5629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is included into payment for code 99223. 
 
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 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 code 99497 
billed for date of service April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick, and gel pads (K0108). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and gel pads (K0108). You say that the requested expandable controller (E2377), expandable controller harness 
(E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the 
joystick, and gel pads (K0108) are medically necessary. The Plan denied your request. The Plan says the 
requested expandable controller (E2377), expandable controller harness (E2313), electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick, and gel pads (K0108) 
are 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 an expandable controller (E2377), 
expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick, and gel pads (K0108). Our reviewer says that the requested expandable 
controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick, and gel pads (K0108) are not medically necessary. 
Our physician reviewer found provided records document that the enrollee has 4/5 bilateral upper extremity 
strength with no documented "limitations", "contractures", "fisting" or "tremors" thus indicating she has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. Provided records do not document why standard pads are inadequate and why the requested gel pads 
(K0108) are medically necessary, and thus they do not meet Medicare coverage criteria. 
 
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 (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and gel pads (K0108) have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick, and gel pads (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hard metal support for a cap on tooth #29 (code D2950) 
and a tooth-colored cap with no metal for tooth #29 (code D2740). 
 
You asked the Plan to pre-approve codes D2950 and D2740 for tooth #29. You say that you are a cancer 
patient and have an infected tooth. You say that you are taking antibiotics for infection and everything else can 
be stabilized. You say that you have a lot of pain and that a temporary crown will not last long. 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 services was exhausted. Specifically, you received approval for codes 
D2950 and D2740 on tooth #8, #13, and #30 for the 2022 calendar year. Therefore, we decided that the Plan 
does not have to pre-approve hard metal support for a cap on tooth #29 (code D2950) and a tooth-colored cap 
with no metal for tooth #29 (code D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infectious disease (viral respiratory tract infection), 
pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza 
A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as 
detected or not detected] (0241U) provided January 28, 2022. 
 You asked the Plan to pay for the laboratory services. You say that please review for payment. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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 laboratory services have been met. 
with the information provided, the Plan was unable to determine how the enrollee came to the servicing 
provider or whether the services were medically necessary. The Plan made multiple attempts to obtain the 
needed additional from the provider without success. Therefore, we decided that the Plan does not have to pay 
for Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute 
respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus 
[RSV]), upper respiratory specimen, each pathogen reported as detected or not detected] (0241U) provided 
January 28, 2022.