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

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (E2377), harness (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), custom platform (K0108 X2), and extra-large platform (K0108) 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
E2300 Seat Elevator is requested to facilitate transfers. E2300 Seat Elevator does not serve a primary medical 
purpose and is statutorily non-covered.  
 
There is a request for footplate accessories: K0108 Custom Platform and Extra-Large Platform. These are parts 
are miscoded; K0108 must not be used for items that have a specific HCPCS code. 
 
Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS 
code and are not included in another code should be coded K0108." The correct code for footplates are K0040, 
K0041 or K0042. 
 
K0040 has already been approved. K0108 cannot be approved, as parts for the approved footplates are 
unbundled from the approved K0040. E2377 Expandable Controller, E2313 Expandable Controller Harness 
and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline 
and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors 
(E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. Notes show that the member is able to feed self. Upper limb 
strength and function are adequate for the member to be able to control the power options using their 
own switches which are included in the allowance of these power options. The approved power options come 
with their own switches. Therefore, we decided that the Plan does not have to pre-approve power seat elevation 
system (CPT code E2300), expandable controller, including all related electronics and mounting hardware, 
upgrade provided at initial issue (E2377), harness (E2313), electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), custom platform (K0108 X2), and extra-
large platform (K0108)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 4, 2021, billed with codes 
84480, 84481, 85025, 80053, and 83970. 
You asked the Plan to pay for the lab testing. You say that this was medically necessary and should be paid. 
The Plan denied your request. The Plan says the POS code used is not appropriate. 
 
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 testing 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 the lab testing provided on March 4, 2021, billed with codes 84480, 84481, 
85025, 80053, and 83970.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) precision attachments (D5862). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental 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 eight 
(8) precision attachments (D5862).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifteen (15) additional skilled physical therapy (PT) 
visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria.  
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 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 additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the plan. The enrollee has had 
prior 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, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was already 
approved. The enrollee can transition to an independent home exercise program. 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 patient's current condition or to prevent or 
slow further deterioration. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve fifteen (15) additional skilled physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported retainer crowns (D6075) for teeth # 
19 and 21. 
 
You asked the Plan to pre-approve the dental services. You say that the middle tooth cannot be considered a 
crown because it is not completely there. You say that it has been a year since the original implant was put in. 
You also say that there is a chance it will become dangerous if it is not covered. The Plan denied your request. 
The Plan says implant supported retainer crowns are not listed as covered services. 
 
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 implant supported 
retainer crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve implant supported retainer crowns (D6075) for teeth # 19 and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom abutments (D6057) and two abutment 
supported crowns (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you do 
not feel that they are related to implant services. The Plan denied your request. The Plan says these services are 
not covered by your dental 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. The procedure codes for these services (D6057 and D6058) are not 
listed as covered services in your contract, which lists the types of services covered and the procedure codes to 
which these services are limited. In addition, the Plans contract states that tooth implants and transplants 
including supported crowns and any associated care for implant placement are not covered. The requested services are supported crowns and services to support these crowns. Therefore, we decided that the Plan does 
not have to pre-approve two custom abutments (D6057) and two abutment supported crowns (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection (E2311). You say that the requested electronic 
connection (E2311) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic connection (E2311). 
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 an electronic connection (E2311). Our 
reviewer says that the enrollee does not meet criteria for the requested electronic connection (E2311). Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
meets the Local Coverage Article criteria for the requested electronic connection (E2311). Provided records 
document that the enrollee has up to 4+/5 left upper extremity strength and is independent with eating thus 
indicating she has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection (E2311) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor knee (coded as L5845, L5848, 
L5850, L5856) for an approved prosthesis with high activity control frame (L5930) and lithium ion battery (L7368). 
You asked the Plan to pre-approve the requested type of knee components and lithium ion battery. You say that 
the requested components are necessary. The Plan denied your request. The Plan says the enrollee's functional 
level does not support that the requested type of knee is required. 
 
The Plan follows Medicare rules. Medicare rules say that certain types of knee prosthetics can only be covered 
when the enrollee has a certain functional level. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested type of knee components 
and lithium ion battery. Our reviewer says that the documentation does not support that the enrollee's functional 
level is sufficient to support the medical necessity of these components. Our physician reviewer found based on 
the medical records provided there is no documentation that supports the enrollee is (or soon will have the 
potential to be) a level 3 ambulator to meet criteria for the type of knee requested. Medical records from the 
treating medical provider do not include any detailed physical examination supporting that she is or has the 
potential to be a level 3 ambulator. Records indicate her goal is to be able to use a walker; this is not consistent 
with level 3 ambulation.  
 
The lithium battery code requested is not approvable on initial issue as it is included with the related 
component. This can only be separately paid for replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested type of knee components and lithium ion battery have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the microprocessor knee (coded as 
L5845, L5848, L5850, L5856) for an approved prosthesis with high activity control frame (L5930) and lithium 
ion battery (L7368).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits. 
You asked the Plan to pre-approve the 6 additional home health visits. You say that you would like 
reconsideration because the additional home health visits are medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a skilled nursing need provided. 
 
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 the 6 additional home health visits. Our 
reviewer says that the documentation doesn't support that the member requires additional skilled nursing 
services to provide treatment that is medically necessary. Our physician reviewer found the member does not 
require additional skilled nursing  services to effectively provide treatment, care, and/or services in order to 
improve the member's condition, perform a maintenance program to maintain the member's condition and/or 
prevent deterioration. The member has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. 
 
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 6 additional home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth # 12 and 13. 
 
You asked the Plan to pre-approve the dental services. You say that you can no longer have a crown or do a 
root canal. You say that the roots have been infected due to the cavities. You also say that your doctor 
prescribed it since it is medically necessary. The Plan denied your request. The Plan says implants 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 endosteal implants are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010) for teeth # 12 and 13.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-five (25) additional skilled occupational therapy 
(OT) visits 
 
You asked the Plan to pre-approve additional OT visits. You say that the requested additional OT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional OT visits do not 
meet criteria.  
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 additional OT 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 enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's medical condition. 
 
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 OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twenty-five (25) additional skilled occupational therapy (OT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that the representative informed the 
dental office that this service was covered. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's 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 
mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and post and core in addition to a 
crown (D2952) for tooth # 25. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says that requested dental services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested dental services are not medically necessary. Our physician reviewer found that anterior teeth 
have a very high survival rate without the need for crowns despite endodontic treatment. The reviewer found 
that post and cores are foundation restorations in cases where there is not enough structure to retain a crown, if 
a crown is indicated. The reviewer found that given the amount of structural damage to tooth # 25, and the limited incisal chipping of the tooth, the criteria for crowns would not be met, and therefore a post and core 
would also not be necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and post and core in addition to a crown (D2952) for tooth # 25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), implant supported crown (D6066), and sinus augmentation 
(D7952). 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, implant supported 
crown, and sinus augmentation. You say that implants were covered in 2021 but your dentist did not submit the 
request on time for it to apply to your 2021 benefits. The Plan denied your request. The Plan says these services 
are not covered under your benefit plan. 
 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), implant 
supported crown (D6066), and sinus augmentation (D7952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066), and a 
prefabricated abutment (D6056) for tooth #30 to be provided by a participating provider. 
 
You asked the Plan to pre-approve an implant supported crown and a prefabricated abutment. You say that you 
would like the Plan to approve and pay for this dental work. The Plan denied your request. The Plan says the 
requested dental services are 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 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 pre-approve an 
implant supported crown (D6066), and a prefabricated abutment (D6056) for tooth #30 to be provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult and two root canals to be provided by an 
endodontist. 
 
You asked the Plan to pre-approve the consult and root canals. You say that the endodontist would be cheaper 
to work with than going to the emergency room for so many visits. The Plan denied your request. The Plan 
says these services are not covered. 
 
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. These services are also not covered when they are received by anyone 
other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a 
consult and two root canals to be provided by an endodontist.