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

 
We decided that the Plan does not have to pre-approve a power seat elevation (E2300) and power standing 
seating system (E2301) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation and standing systems. You say that the requested 
items should be approved. The Plan denied your request. The Plan says all requested items were approved aside 
from E2300 and E2301, as these are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
Although this may be appropriate for the enrollee, these types of features are not covered by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation (E2300) and power 
standing seating system (E2301) for an approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup and crown on tooth #30. 
 
You asked the Plan to pre-approve the services. You say that the plan is not accepting what the dentist wants to 
do. The Plan denied your request. The Plan says the x-ray submitted shows furcation involvement on tooth #30, 
indicating the presence of advanced periodontal disease and poor prognosis for a buildup and crown. 
 
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 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found tooth #30 has an 
existing two surface amalgam restoration that does not appear to have any recurrent decay. Crowns are 
typically considered where there is 50% or more damaged or missing structure of a tooth so that function may 
be maintained.  In this instance there is minimal structural loss from a prior restoration involving less than 30% 
of the structure, and no clear need to restore the tooth with a fill coverage restoration. A core buildup is a 
service only necessary if a crown is needed and there is insufficient structure to allow for its retention, which is 
not the case in this instance.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a core buildup and crown on tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive oral 
evaluation (D0150) provided by a participating provider on February 8, 2022. 
 
You asked the Plan to pay for intraoral imaging and a comprehensive oral evaluation. You say that you have 
not had any dental work in two years. The Plan denied your request. The Plan says the benefit limit for these 
services have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral 
imaging every five years, and one comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 and D0150 were 
previously provided on August 19, 2020. Based on this information, we decided that the Plan's rules for 
coverage of intraoral imaging and a comprehensive oral evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive oral evaluation (D0150) 
provided by a participating provider on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81321) provided on August 3, 2021. 
 
You asked the Plan to pay for code 81321. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81321) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you had a prior authorization for a partial 
which was denied, and you would like to appeal the Plan's decision. The Plan denied your request. The Plan 
says these services exceed the maximum counts allowed per period. 
 
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, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on July 23, 
2021 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213) and a mandibular partial denture (D5214).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold pack therapy (97010) provided on December 3, 2021. 
You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this procedure is not paid separately. 
 
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 find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold pack therapy (97010) provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
December 20, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told you had a $1,000 allowable amount 
for 2021. The Plan denied your request. The Plan says these services have correctly been denied. 
 
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 dental 
services up to a $750 combined allowance for supplemental preventive and comprehensive dental services 
every year.  
 
We looked at 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 pay for 
dental services provided by an out-of-network provider on December 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 11, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers 
associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Insertion of temporary indwelling bladder catheter; simple 
(51702) provided April 23, 2021. 
 
You asked the Plan to pay for the procedure. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says this is denied for unbundled services. 
The provider did not bill as required by Medicare coding regulations. 
 
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 51702 
is a column II code to column I code 51600 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Insertion of temporary indwelling bladder 
catheter; simple (51702) provided April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee has type II diabetes 
and is requesting to use this product. The Plan denied your request. The Plan says the enrollee does not meet 
prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (K0553).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided 
October 1, 2021 to October 22, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that your billing was declined and you 
challenging that you are ineligible to provide services. The Plan denied your request. The Plan says services 
was rendered by a mental health counselor. This provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services 
(90834) provided October 1, 2021 to October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided August 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. As of the date of service in question, this service was listed as non-
covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing 
(81455) provided August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88108, 88305) provided June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 find that CPT codes 88108, & 88305 are not supported in the medical record. Specifically, the records 
support one unit each of these CPT codes. One unit each was already approved and paid. Additional units are 
not supported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (88108, 88305) 
provided June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on May 25, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the root canal. You say that your dentist advised you to get a root canal, and you 
do not understand why half of the approved amount is not covered. The Plan denied your request. The Plan 
says the treating provider is not part of the Plan's network of dental providers. The Plan also says that there was 
no authorization or request for an authorization for this service to be covered OON. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the root 
canal (D3330) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will not be successful if you do not get intensive 
rehabilitation throughout the day. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided June 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Additionally, the records 
show that this service was initiated by the laboratory and not ordered by the enrollee's physician. Therefore, we 
decided that the Plan does not have to pay for lab services (81479) provided June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits 
(G0151). 
 
You asked the Plan to pre-approve additional home health PT visits. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health PT visits. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician 
reviewer found that skilled therapy services are not required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to 
maintain the enrollee's level of function and/or prevent deterioration. The enrollee is at a high functional level 
and has had safety instruction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental 
pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and a segmental pneumatic appliance. You say that 
the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for 
coverage for out-of-network services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0651) and a segmental pneumatic appliance (E0667) to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) and resin-
based composite of two surfaces (D2392) provided on February 8, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray and resin-based composite. You say that 
you are on a fixed income, and it is difficult for you to make this payment. The Plan denied your request. The 
Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year and restorations are limited to 2 procedure codes per calendar year. The 
record shows that you received a first intraoral periapical x-ray (D0220) and two resin-based composites of one 
surface (D2391 x2) on February 8, 2022 and your intraoral x-rays and restorations benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray 
(D0230) and resin-based composite of two surfaces (D2392) provided on February 8, 2022.