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

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, test socket, above knee 
(L5624 x2), an addition to lower extremity, above knee or knee disarticulation, acrylic socket (L5631), an 
addition to lower extremity, above knee, flexible inner socket, external frame (L5651), an addition to lower 
extremity, above knee, flexible inner socket, external frame (L5705), an addition, endoskeletal knee-shin 
system, single axis, fluid swing and stance phase control (L5828x1) and an addition to endoskeletal knee-shin 
system, fluid stance extension, dampening feature (L5848). 
 
You asked the Plan to pre-approve additional lower extremity prosthetics. You say that you disagree with the 
denial. The Plan denied your request. The Plan says based on Medicare guidelines and the information about 
the enrollee's condition, he does not meet the requirement for the requested items. 
 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 lower extremity prosthetics. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an addition, endoskeletal knee-shin system and a fluid stance extension are 
non-covered since the functional level is K2. The documentation does not reveal a recent face to face within 6 
months for the requested items. The medical necessity has not been met per Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity prosthetics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an addition to lower extremity, test socket, above knee (L5624 x2), an 
addition to lower extremity, above knee or knee disarticulation, acrylic socket (L5631), an addition to lower 
extremity, above knee, flexible inner socket, external frame (L5651), an addition to lower extremity, above 
knee, flexible inner socket, external frame (L5705), an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828x1) and an addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature (L5848).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a panoramic 
radiographic image (D0330), surgical placement of an implant (D6010 x2), an extraction (D7210), bone 
replacement graft (D7953), deep sedation/general anesthesia (D9223), an unspecified preventive procedure 
(D1999) and the dental services described by code D0001 provided from May 9, 2022, through May 20, 2022, 
by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. Additionally, panoramic radiographic images, implants, bone replacement grafts, unspecified preventive procedure, the dental services described by code D0001, or deep 
sedation/general anesthesia for the non-covered services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330), surgical 
placement of an implant (D6010 x2), an extraction (D7210), bone replacement graft (D7953), deep 
sedation/general anesthesia (D9223), an unspecified preventive procedure (D1999) and the dental services 
described by code D0001 provided from May 9, 2022, through May 20, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), an expandable 
controller harness (E2313) and an electronic connection between wheelchair controller and two or more power 
seating system motor (E2311). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the power tilt, power recline, and 
power seat lift options are necessary for the enrollee. The Plan denied your request. The Plan says there is not a 
medical need to control these power options through the joystick. 
 
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.  
 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 service is not medically necessary. Our physician reviewer found the enrollee has adequate 
strength to operate standard switches on a power wheelchair. She has impaired upper extremity strength, but 
she is able to pull her body away from the back of the wheelchair to weight shift. It is not medically necessary 
for her to control the multiple power drives from a single source. The expandable controller and associated 
accessories exceed the services necessary to meet the enrollee's needs. 
 
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 an expandable controller (E2377), an expandable controller harness (E2313) and 
an electronic connection between wheelchair controller and two or more power seating system motor (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 8, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) for tooth #9 
provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed by your provider that 
only one tooth every 36 months is covered. 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 item or service was exhausted on date of service June 22, 2022, with tooth 
#8. Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) 
for tooth #9 provided on June 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says the remaining 12 physical therapy visits are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee was approved for therapy and can be re-evaluated 
upon completion of the already approved 12 therapy sessions to see if she needs a professional therapist to 
safely and effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27357 billed for date of service May 20, 2022. 
 
You asked the Plan to pay for code 27357. You say that this service was billed correctly and should be paid. 
The Plan denied your request. The Plan says code 27357 is inclusive to code 27447 
 
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 27357 is Excision or curettage of bone cyst or benign 
tumor of femur; with autograft (includes obtaining graft) in addition to medial and lateral knee arthroplasty 
 
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 code 27357. Our reviewer says that code 27447 is not 
supported for separate payment. Our reviewer found the operative report does not include sufficient documentation to confirm excision of cyst or benign tumor was a separate and distinct procedure from the 
primary procedure. The operative report documents "The knee was then sized after the distal femoral cut had 
been made... The debris from the back of the knee including meniscal remnants were removed, as well as all 
osteophytes".  In this case, the operative report does not describe the procedure, excision of osteophytes to 
confirm it was a separate procedure.  Per NCCI Policy "Curettes or osteotomes are used to scrape or cut the 
lesion from the bone. Once the benign tumor or cyst is removed and healthy bone tissue is present, the 
periosteum is repositioned and the incision is repaired in layers. If the bone defect created requires a graft for 
repair, the physician obtains the necessary size bone graft from a separate donor site on the patient and packs it 
into the site where the tumor or bone cyst was removed or uses a bone bank allograft. Report 27356 if an 
allograft is used and 27357 if an autograft is obtained". The operative report does not describe details of this 
procedure and therefore cannot be confirmed as a separate procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27357 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 27357 billed for date of service May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 10, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, a transit package (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the item in question is not an integral part of the wheelchair base and is for 
the comfort or convenience of the enrollee. 
 
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 wheelchair accessory, a transit package (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions 
(D7310). 
 
You asked the Plan to pre-approve alveoloplasty not in conjunction with extractions. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty not in conjunction with extractions (D7310).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 5, 2022.

You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. 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 70450 billed for date of service July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support 
the need for the requested inpatient admission. The Plan denied your request. The Plan says the enrollee does 
not meet any of the requirements for an inpatient stay. The Plan says that, if medical issues develop, they will 
review upon request. 
 
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 pre-approve the inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at significantly increased risk for peri-surgical 
complications requiring an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the record does not show that at the time of the request for an inpatient admission, the admitting physician 
reasonable expected that the enrollees necessary hospital care would span two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the requested item does not serve a primary medical 
purpose and is statutorily non-covered. 
 
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 wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330) and intraoral imaging 
(D0230) provided by a participating provider on January 26, 2022, to March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. You say 
that this is not about revenge. 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 D0230 was exhausted on date of service January 26, 2022, and D2330 was exhausted on 
date of service March 1, 2022. Therefore, we decided that the Plan does not have to pay for a resin-based 
composite (D2330) and intraoral imaging (D0230) provided by a participating provider on January 26, 2022, to 
March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-ray 
(D0274), and the cleaning (D1110) provided on April 20, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation (D0120), the bitewing x-ray (D0274), and the 
cleaning (D1110). You say that your coverage changed from 100% to 55% coverage. You say you were not 
notified of any coverage changes for the year 2022. The Plan denied your request. The Plan says the claim was 
paid correctly. 
 
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 were 
covered under this benefit. Specifically, the Plan paid 100% of the allowed amounts for the services. Therefore, 
we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-ray 
(D0274), and the cleaning (D1110) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x2) provided on June 9, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you were not aware that the service was not 
covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921 x2) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), a core build-up (D2950), and a 
gingivectomy (D4211), provided by an out-of-network provider on December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not told that this would not be 
covered. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, D2740 and D2950 are not covered under this benefit 
when received from an out-of-network provider. D4211 is not a covered benefit. Therefore, we decided that the 
Plan does not have to pay for a crown (D2740), a core build-up (D2950), and a gingivectomy (D4211), 
provided by an out-of-network provider on December 2, 2021.