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

 
We decided that the Plan does not have to pre-approve a complete right shoulder replacement procedure. 
 
You asked the Plan to pre-approve the requested shoulder surgery. You say that you have been having shoulder 
pain for some time and want the Plan's doctors to fix the issue. You say that no one at the Plan wants to help 
you, but you need surgery to be approved. The Plan denied your request. The Plan says the requested procedure 
is not medically necessary as it is not likely to resolve your condition and would lead to functional deficits. 
 
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 shoulder surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this 60-year-old male was being treated for a rotator cuff tear. He presented with 
right shoulder pain. The pain is diffuse in the shoulder and is exacerbated with overhead activity. Advanced 
imaging of the right shoulder dated 12/5/21 was noted to show a massive tear in the supraspinatus with 
retraction to the glenoid and grade 4 atrophy; biceps, subscap, and cartilage intact; superior infraspinatus is 
likely also torn. X-rays from this dated are noted to demonstrate no obvious fractures, dislocations, or 
osteoarthritis of the glenohumeral joint.   
There is no evidence of any significant osteoarthritis of the right shoulder. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. Additionally, 
both his treating physician and the consulting physician concluded he was not an optimal candidate for surgery. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested shoulder replacement surgery, 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 shoulder surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a complete right shoulder replacement procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing, four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you want the service to be covered. The 
Plan denied your request. The Plan says medical necessity has not been established. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services 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 dental services. Our reviewer says 
that the requested treatment is not medically necessary. Our physician reviewer found code D4341 is reserved 
for instances where four or more teeth in a quadrant are periodontally involved as referenced by a loss of 
clinical attachment. Although there are areas of periodontal pocketing noted, the x-rays do not show signs of 
any significant bone loss or exposure of the roots to the oral environment from attachment loss in any of the 
four quadrants. As D4341 is a code reserved for treatment of periodontitis, the requested treatment would not 
be medically 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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing, four or more teeth per quadrant (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823) and 
related accessories. 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair and accessories. You say that the 
requested power wheelchair is a medical necessity for you. The Plan denied your request. The Plan says rules 
for coverage of a PMD have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
  The file does not show that you have a mobility deficit that impairs your participation in MRADLs, that your 
condition cannot be improved by a walker, cane or manual wheelchair, and that you can safely operate the 
PMD being requested. An independent seating and mobility evaluation has not been provided. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 standard power wheelchair (K0823) and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service April 30, 
2022. 

You asked the Plan to pay for procedure code 99051. You say that payment should be made for these services. 
The Plan denied your request. The Plan says procedure code 99051 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service April 30, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you believe the services are medically necessary. 
The Plan denied your request. The Plan says that your care could be provided at a lower level of care like in a 
long-term care facility or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is sufficient clinical documentation showing that you have new functional 
impairments and wound care needs. Clinical documentation shows that you require skilled nursing for wound 
assessment and clinical assessments.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 17, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that this should not be denied as bundled 
because you voided the prior claim, and this claim is the corrected claim. The Plan denied your request. The 
Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service April 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to predominantly base metal 
(D2751) Tooth 18 and 30. 
 
You asked the Plan to pre-approve dental services. You say that if you don't get the requested services, it will 
make it difficult to eat and have normal oral function. The Plan denied your request. The Plan says the 
requested crown - porcelain fused to predominantly base metal (D2751) Tooth 18 and 30 is not approved 
because enough tooth remains for a filling. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services 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 dental services. Our physician reviewer 
found the teeth have existing one surface restorations. Number 30 has apparently lost one cusp with no other 
caries noted.  Number 18 has mesial and distal caries. Neither of these teeth have more than 40% of the 
structure missing.  Crowns are usually indicated where 50% or more of the tooth is damaged or fractured and a 
conventional restoration would to be sufficient to restore function. In this instance, as there is sufficient 
structure to restore the teeth without a crown, the requested services are not medically 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crown - porcelain fused to predominantly base metal (D2751) Tooth 18 and 30.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88381 and 88360 billed for 
date of service January 21, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88381 and 88360. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88381 
and 88360. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88381 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88381 and 88360 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88381 and 88360 billed for date of service January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute-care hospital where the enrollee is currently receiving care. The Plan has approved ongoing care in the 
current acute-care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a level 3 prosthetic foot. 
 
You asked the Plan to pre-approve the requested foot. The Plan denied your request. The Plan says the enrollee 
being a K3 ambulator is not supported by the medical record. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  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 foot. Our physician 
reviewer found that a level 3 ambulator has the ability or potential for ambulation with variable 
cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and 
may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple 
locomotion. In this case, the documentation does not support that the enrollee is able to ambulate at a K3 
functional level. The documentation indicates the enrollee requires an assistive device for mobility. Therefore, 
the upgraded foot is not medically 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 foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a level 3 prosthetic foot.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue exam by a pathologist (88304) provided on May 26, 
2021. 
 
You asked the Plan to pay for a tissue exam. You say that you needed updated coding from the treating facility. 
The Plan denied your request. The Plan says this claim wasn't filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a tissue exam was not filed until June 14, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for a tissue exam by a pathologist (88304) provided on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a back-up CPAP battery. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a CPAP device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM sensor. You say that you were previously told by a 
sales rep that the product would be covered. The Plan denied your request. The Plan says Medicare does not 
cover the Freestyle Libre 3 CGM as the Freestyle Libre 3 CGM does not have a stand-alone receiver, nor is it 
integrated into an insulin pump. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 CGM sensor have not been met. Specifically, the requested CGM device does 
not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the 
Plan. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM) sensor (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Toric intra-ocular lenses 
 
You asked the Plan to pre-approve Toric intra-ocular lenses. You say that you have extreme astigmatism, and a 
standard lens will not help with astigmatism. You need the Toric lenses to remedy the astigmatism. The Plan 
denied your request. The Plan says the requested specialty intraocular lens is not covered under the Plan 
benefits. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve Toric intra-
ocular lenses
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame /table system with seat 
lift feature. 
 
You asked the Plan to pre-approve a combination sit to stand frame /table system with seat lift feature. You say 
that you feel this item should be covered. The Plan denied your request. The Plan says the requested item is not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item 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. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand frame /table system with seat lift 
feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee needs this injection. The Plan denied 
your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate the enrollee has had 50% pain relief for at least 3 months. Therefore, the reviewer found that a repeat 
ESI is not medically necessary at this time. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service September 22, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that these services 
were reported correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service September 22, 2021.