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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed.
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37228-RT billed for November 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 37228 is not supported. 
 
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 37228 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 
 
We find that CPT code 37228 is not supported in the medical record. Specifically, there is no documentation of 
an open or percutaneous endovascular revascularization of a unilateral tibial or peroneal artery for the initial 
vessel. 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 procedure code 37228-RT billed for 
November 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that the enrollee had manipulation. You also 
say that they need to continue therapy. The Plan denied your request. The Plan says the additional 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 8 additional PT 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 the provided documentation indicates the enrollee has had 
prior extensive therapy and the documentation does not reveal that the enrollee requires the ongoing unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. The reviewer found that the enrollee can transition to an 
independent home exercise program (HEP) with the already approved therapy. Therefore, the reviewer found 
that the additional PT visits are 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 8 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system coded as E2300 for use 
with an approved power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation system. You say that all requested features are 
needed. The Plan denied your request. The Plan says the power wheelchair has been approved aside from the 
E2300 feature as this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation features are not covered as 
they are not primarily medical in nature. 
 
Although this feature may be appropriate, neither Medicare nor the Plan provides coverage for this. Therefore, 
we decided that the Plan does not have to pre-approve the power seat elevation system coded as E2300 for use 
with an approved power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of flow cytometry (88184, 88185).

You asked the Plan to pre-approve flow cytometry. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services 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 flow cytometry. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that, per the available medical records, the enrollee's condition is probably not polycythemia vera but secondary polycythemia. Flow cytometry is not recommended in the enrollee's clinical situation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of flow cytometry have not been met. Therefore, we decided that the Plan does not have to pre-approve the use of flow cytometry (88184, 88185).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontics (D6245 x 2) and retainer crowns 
(D6740 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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. 
 
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 the 
pontics (D6245 x 2) and retainer crowns (D6740 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and pulp 
vitality tests (D0460) provided on December 28, 2022. 
 
You asked the Plan to pay for limited oral evaluation and pulp vitality tests. You say that this should be 
covered. The Plan denied your request. The Plan says these are not covered services. 
 
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, 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 limited 
oral evaluation - problem focused (D0140) and pulp vitality tests (D0460) provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954) 
provided on November 29, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not be billed for out-of-network because 
the provider sold their business to another provider. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
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. Prefabricated post and core in 
addition to crown (D2954) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2954 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for prefabricated 
post and core in addition to crown (D2954) provided on November 29, 2022.
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 November 
11, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 2,800 Contour Next test strips and lancets. 
 
You asked the Plan to pre-approve the additional 2,800 Contour Next test strips and lancets. You say that you 
are owed the additional strips and lancets. You also say that the doctor sent in  letters of medical necessity for 
the past years saying you need this  amount. The Plan denied your request. The Plan says the amount of BG 
strips and lancets is excessive as requesting 1000 Contour Next blood glucose strips and 1000 lancets every 90 
days. 
 
The Plan follows Medicare rules. Medicare rules say that  a beneficiary who is currently being treated with 
insulin administrations, up to 300 test strips and up to  300 lancets every 3 months are covered if basic 
coverage criteria (1)-(2) (above) are met.. 
 
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 additional Contour Next test strips 
and lancets. Our reviewer says that these items are not medically necessary. Our physician reviewer found the 
provided records in this case include an office visit note reporting the patient tests his glucose five or more 
times per day; the medical records do not document the patients tests 11 times per day and records do not 
document the specific quantity of supplies that exceeds the usual utilization amounts described above as 
required by the LCD. A prescription is not considered to be part of the medical record. Medical information 
intended to demonstrate compliance with coverage criteria may be included on the prescription but must be 
corroborated by information contained in the medical record. The beneficiarys medical record must contain 
sufficient documentation of the beneficiarys medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). The information should 
include the beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the 
beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. 
 
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 additional 2,800 Contour Next test strips and lancets have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an additional 2,800 Contour Next test strips 
and lancets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty with extractions (D7311) on tooth #s 
25, 26, 27. 
 
You asked the Plan to pre-approve the alveoloplasty with extractions (D7311) on tooth #s 25, 26, 27. You say 
that you are appealing the denial due to qualify of life issues. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the alveoloplasty with extractions (D7311) on tooth #22 was approved on appeal which means the Plan 
limits have been met. Therefore, we decided that the Plan does not have to pre-approve the alveoloplasty with 
extractions (D7311) on tooth #s 25, 26, 27.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five home health physical therapy visits.

You asked the Plan to pre-approve home health services. You say that the requested home physical therapy visits are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

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 home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have documented skilled therapy needs. The enrollee is functioning at a level appropriate for a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve five home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011) Tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial for the 
requested services. 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. This benefit includes the 
requested surgical access to an implant body (second stage implant surgery) (D6011) but is limited up to two 
(2) implants covered per year, or up to four (4) implants covered per year for edentulous patients. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows with the pre-approval of surgical access to an implant body (second stage implant surgery) (D6011) 
Tooth #29 and 31, this exhausted your benefit. The dates of your approval are April 4, 2023, to July 3, 2023. 
Therefore, we decided that the Plan does not have to pre-approve surgical access to an implant body (second 
stage implant surgery) (D6011) Tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the swallowing function x-ray (74230), upper gastrointestinal 
tract x-ray (74240) and the office visit (99204) provided on November 22, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. 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 [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. The documentation supports the studies represented by Current 
Procedural Terminology (CPT) were performed at a nursing home (via mobile van/portable x-ray) which are 
denied as an excluded place of service. In addition, the POS 11 is not supported. The provider did a barium 
swallow study in the portable mobile radiology setting. That imaging requires both the use of fluoroscopy AND 
contrast which is the barium swallow solution, which is also considered a substance administered to the patient. 
This type of imaging is not covered by Medicare in the mobile setting. Therefore, we decided that the Plan does 
not have to pay for the swallowing function x-ray (74230), upper gastrointestinal tract x-ray (74240) and the 
office visit (99204) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider relies on the facility staff to 
obtain the necessary authorizations. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on 
December 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee replacement surgery. 
 
You asked the Plan to pre-approve total knee replacement surgery. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this is 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 total knee replacement surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less-invasive conservative care measures. There is no indication of recent formal 
therapy for the knee. Additionally, no injections have been documented to have been tried and failed, outside of 
cortisone. The formal diagnostic studies were not provided for review to corroborate significant osteoarthritis in the left knee. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical 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 total knee replacement surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve total knee replacement surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is needing close medical supervision due 
to the type of surgery the enrollee had. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.