Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient care after March 14, 2023.

You asked the Plan to pre-approve inpatient care after March 14, 2023. You say that you did not agree with being discharged. The Plan denied your request. The Plan says the 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 inpatient care after March 14, 2023. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no medical necessity for inpatient hospital services after March 14, 2023.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care after March 14, 2023, have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient care after March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intramuscular/subcutaneous injection (96372). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of subcutaneous/intramuscular injection 
as a mode of administering Synvisc One in the setting of osteoarthritis have not been demonstrated in the peer-
reviewed literature. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the intramuscular/subcutaneous injection (96372) for Synvisc 
One (J3725) at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for the enrollee, per Social Security Act, Section 1862(a)1(A). As documented in the Medicare-approved major drug compendia, Synvisc One is only medically reasonable and necessary and safe and 
effective for intra-articular injection for osteoarthritis of the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intramuscular/subcutaneous injection (96372).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on July 27, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary because the enrollee is 
unable to obtain prior functional status. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of a partial denture. 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 October 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 21, 
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 October 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested scooter is medically necessary. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty POV is covered for a beneficiary 
weighing 285  450 pounds. 
 
We looked at the file and Medicare rules. The medical record shows the enrollee only weighs 157 pounds. 
Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power scooter (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair and accessories. 
 
You asked the Plan to pre-approve a Group 3 Power Wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
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 a Group 3 Power Wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not require alternative to standard switches, is not at high risk for skin breakdown, and does not 
have spasticity. Criteria for power drives or a group3 power wheelchair are not met. 
 
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 Group 3 Power Wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2740x2), the endodontic therapy, anterior 
tooth (D3310x2), the prefabricated post and core in addition to crown (D2954x2), the surgical placement for 
isolation of tooth with rubber dam (D3910x5), the surgical access to an implant body (D6011x2), the cone 
beam CT capture and interpretation (D0366), and the pulpal debridement (D3221x5). 
 
You asked the Plan to pre-approve the crowns (D2740x2), the endodontic therapy, anterior tooth (D3310x2), 
the prefabricated post and core in addition to crown (D2954x2), the surgical placement for isolation of tooth 
with rubber dam (D3910x5), the surgical access to an implant body (D6011x2), the cone beam CT capture and 
interpretation (D0366), and the pulpal debridement (D3221x5). You say that the services are extremely 
necessary because she experiences pain while eating. The Plan denied your request. The Plan says the surgical 
placement for isolation of tooth with rubber dam (D3910x5), the surgical access to an implant body (D6011x2), 
the cone beam CT capture and interpretation (D0366) are not covered services. The Plan says that the benefits 
have been exhausted for the crowns (D2470x2), the endodontic therapy, anterior tooth (D3310x2), and the 
prefabricated post and core in addition to crown (D2954x2). The Plan says you do you not meet the criteria for 
the pulpal debridement (D3221x5).  
 
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 surgical placement for isolation of 
tooth with rubber dam (D3910x5), the surgical access to an implant body (D6011x2), the cone beam CT 
capture and interpretation (D0366) are not among those covered under this benefit.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the crowns (D2740x2), the endodontic therapy, anterior tooth (D3310x2), and the 
prefabricated post and core in addition to crown (D2954x2) were exhausted because they exceed Plan limits.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the pulpal debridement (D3221x5) is not eligible for coverage because you exceed the 
age limit requirement. 
 
Therefore, we decided that the Plan does not have the crowns (D2740x2), the endodontic therapy, anterior 
tooth (D3310x2), the prefabricated post and core in addition to crown (D2954x2), the surgical placement for 
isolation of tooth with rubber dam (D3910x5), the surgical access to an implant body (D6011x2), the cone 
beam CT capture and interpretation (D0366), and the pulpal debridement (D3221x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were referred for services. The Plan denied 
your request. The Plan says this service is not covered as part of a medical eye exam.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. In this case the refraction was performed during a medical eye exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the fees applied for the gym membership 
provided from December 26, 2021, through June 26, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the fees are not payable as the charges 
submitted are not clearly identified. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the expenses and the account 
numbers submitted have not been clearly identified in the documentation provided. The documentation 
provided must clearly indicate the account number that pertains to your membership. Additionally, the monthly 
fees applicable to this membership should be stated in your contractual agreement with the provider. Therefore, 
we decided that the Plan does not have to issue reimbursement of the fees applied for the gym membership 
provided from December 26, 2021, through June 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment  includes modification and 
placement (D6056), and implant supported porcelain/ceramic crown (D6065) all for tooth #'s 20, 21, and 29. 
 
You asked the Plan to pre-approve codes D6056 and D6065. You say that the treatment was started in which 
the screws were placed. You also say that treatment cannot be finished due to the denial of these services. The 
Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 a 
prefabricated abutment  includes modification and placement (D6056), and implant supported 
porcelain/ceramic crown (D6065) all for tooth #'s 20, 21, and 29.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 
12, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, cleaning, crown, occlusal guard, 
bitewing x-rays, limited oral evaluation, and intraoral x-ray (D0120, D1110, D2740, D9940, D0274, D0140, 
D0220). 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the occlusal guard, limited oral evaluation, and 
intraoral x-ray denied correctly as they do not fall within your dental benefits. The periodic oral evaluation, 
cleaning, crown, and bitewing x-rays denied correctly as the claim for these services was received more than 12 
months after the initial date of service. 
 
 
  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 occlusal guard, limited oral 
evaluation, and intraoral x-ray are not among those covered under this benefit.   
 
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 the periodic oral evaluation, cleaning, crown, and bitewing x-rays was not 
filed until October 25, 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 periodic oral 
evaluation, cleaning, crown, occlusal guard, bitewing x-rays, limited oral evaluation, and intraoral x-ray 
(D0120, D1110, D2740, D9940, D0274, D0140, D0220).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 1, 
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 December 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with tilt and power recline 
and power elevating leg rests options. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with tilt and power recline and power elevating 
leg rests options. You say that the requested group 3 power wheelchair with tilt and power recline and power 
elevating leg rests options are medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for a group 3 power wheelchair with tilt and power recline and power elevating leg rests 
options. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair with tilt 
and power recline and power elevating leg rests options. Our reviewer says that the enrollee does not meet 
criteria for a group 3 power wheelchair with tilt and power recline and power elevating leg rests options. Our 
physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for mobility. He is 
currently using a manual wheelchair for mobility. The documentation is insufficient in terms of the enrollees 
current level of mobility and function in terms of transfers and performing daily activities. The enrollee is 
noted to require assistance with daily activities, but level of assistance is not provided. He is noted to have 4/5 
motor strength in his upper extremities, and it is not clear why he cannot perform pressure relief. He has no 
history of skin breakdown, and it is not clear why he is at high risk for skin breakdown and requires a power 
wheelchair with power tilt and recline. He also does not have lower extremity spasticity or lymphedema and it 
is not clear why he requires power elevating leg rests or platform. Therefore, the power wheelchair with power 
tilt and recline and power elevating leg rests 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 a group 3 power wheelchair with tilt and power recline and power elevating leg 
rests options have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with tilt and power recline and power elevating leg rests options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve the stair lift. You say that you feel that this item is medically necessary for 
your mobility in the home. The Plan denied your request. The Plan says this is not a device that Medicare can 
cover. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.