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

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) and switch fender lights without lift system (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the accessories were requested to meet 
the enrollee's in-home medical, functional, and mobility needs throughout his day. The Plan denied your 
request. The Plan says there is not a medical need to control power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file, and Medicare rules. The records show the enrollee can feed independent. The enrollee's 
wrist and hand strength are 3/5 and upper extremity strength is 3-4 out of 5. There is not a medical need to 
control the power options through the joystick. The switch fender lights in this appeal do 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. 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 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
and switch fender lights without lift system (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a semi-electric hospital bed (E0261, A9901) provided on September 30, 2022.

You asked the Plan to pay for the semi-electric hospital bed. You say that this bed was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 pay for the semi-electric hospital bed. Our reviewer says that the bed was not medically necessary. Our physician reviewer found the records do not document the patient required frequent changes in body position or immediate changes in body position.

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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for a semi-electric hospital bed (E0261, A9901) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multiple density insert (A5512-50) provided on October 
6, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the claim denied for invalid place of service (POS). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The DME service was billed with an 
incorrect POS. The POS was billed with POS code 11- Office. An institution may not be considered the 
individuals home. Therefore, we decided that the Plan does not have to pay for the multiple density insert 
(A5512-50) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81307 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 81307. You say that these services were necessary and are 
supported as billed. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81307 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 81307 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 81307 billed for date of service July 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs (J3490) administered on December 19, 2022.

You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment for this service is included in the global surgery payment.

The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery.

We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global surgery payment for the procedure (20610) provided on the same date of service. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J3490) administered on December 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 26, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that  The Plan denied your request. The Plan says 
Medicare only covers the visits if you get them from a health care provider who accepts assignment. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization per site (D7922). 
 
You asked the Plan to pre-approve dental services. You say that you would like your insurance to cover the 
requested service, it is needed due to mouth pain when eating. 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. . Placement of intra-socket 
biological dressing to aid in hemostasis or clot stabilization per site (D7922) is not covered under the Plans 
dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7922 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve placement 
of intra-socket biological dressing to aid in hemostasis or clot stabilization per site (D7922).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve personal care services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not a Medicare covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99203 provided on May 24, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, review of the file shows that 
the enrollee previously received an office visit of an established patient (code 99214) on May 2, 2022 by the 
same provider. This means code 99203 for a new patient is not supported. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit coded 99203 provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057), abutment supported porcelain/ceramic crown (D6058), and surgical access to an implant body  
(second stage implant surgery) (D6011) all for tooth #'s 30 and 31. 
 
You asked the Plan to pre-approve the dental services. You say that you started your dental treatment in 2022 
and it has been paralyzed to lack of coverage of two dental crowns. The Plan denied your request. The Plan 
says your benefit for the requested services 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 that the Plan approved the services (D6057), (D6058) and (D6011) for tooth #s 28 and 29. Therefore, 
we decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057), abutment supported porcelain/ceramic crown (D6058), and surgical access to an implant body  
(second stage implant surgery) (D6011) all for tooth #'s 30 and 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266) and sinus 
augmentation (D7951) for tooth #3. 
 
You asked the Plan to pre-approve the dental services. You say that you had these services done prior and they 
are necessary for your health. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the guided tissue regeneration and sinus augmentation are not covered by the 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. 
 
  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 
guided tissue regeneration (D4266) and sinus augmentation (D7951) for tooth #3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Hyperparathyroidism Panel provided on October 
18, 2022. 
 
You asked the Plan to pay for the Invitae Hyperparathyroidism Panel. You say that this testing was medically 
necessary to treat the enrollee. The Plan denied your request. The Plan says this testing is not covered under 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the Invitae Hyperparathyroidism Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Invitae Hyperparathyroidism Panel provided on October 18, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel, and Bevacizumab-
awwb. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Paclitaxel, and Bevacizumab-awwb. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drugs are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Carboplatin, Paclitaxel, and 
Bevacizumab-awwb. Our reviewer says that the documentation does not support that the requested drugs are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Stage III well 
differentiated squamous cell carcinoma of the Vulva. The requested regimen is requested as first line therapy. 
The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition.  The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. Therefore, the enrollee does not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin, Paclitaxel, and Bevacizumab-awwb have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel, and 
Bevacizumab-awwb.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), custom 
abutment (D6057) and abutment supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve dental implants. 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 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 
surgical placement of implant body (D6010), custom abutment (D6057) and abutment supported porcelain 
fused to metal crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown tooth #'s 
18 and 19 (D6065), and prefabricated abutment  includes modification and placement tooth #18 (D6056). 
 
You asked the Plan to pre-approve codes D6065 and D6056. You say that you disagree with the denial. 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 an 
implant supported porcelain/ceramic crown tooth #'s 18 and 19 (D6065), and prefabricated abutment  includes 
modification and placement tooth #18 (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4266) Tooth #6 and bone replacement 
graft for ridge preservation - per site (D7953) Tooth #6. 
 
You asked the Plan to pre-approve dental services. You say that you had a tooth break, so you need to have the 
requested services. 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. Gum surgery (D4266) and 
bone replacement graft for ridge preservation - per site (D7953) are not covered under the Plans dental 
benefits 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4266 and D7953 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gum surgery (D4266) Tooth #6 and bone replacement graft for ridge preservation - per site (D7953) Tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve dental services. You say that you would like your insurance to cover the 
requested services. 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. Complete upper denture and 
complete lower denture are not covered under the Plans dental services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110 and D5120 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. 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 cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics will help resolve the 
enrollee's pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease, and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction (D7210), anesthesia (D9222, D9223), 
therapeutic parenteral drugs (D9612), alveoplasty (D7310) and removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve dental services. You say that your teeth are busted and starting to break. 
You are diabetic and are worried your dental issues will make your condition worse. 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 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 
extraction (D7210), anesthesia (D9222, D9223), therapeutic parenteral drugs (D9612), alveoplasty (D7310) 
and removal of torus mandibularis (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization services coded 37233 provided on 
September 8, 2022. 
 
You asked the Plan to pay for the revascularization services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are 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 37233 is revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty 
within the same vessel, when performed (List separately in addition to code for primary procedure). 
 
 We find that CPT code 37233 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an open or percutaneous endovascular revascularization; therefore, code 37233 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for the 
revascularization services coded 37233 provided on September 8, 2022.