Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your x-ray was submitted, so you would 
like the requested services approved. 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. This benefit includes the 
requested mandibular partial denture - cast metal framework with resin denture bases (including retentive/ 
clasping materials, rests and teeth) (D5214) but is limited to one every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you had covered mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214) on date of service July 24, 2019; therefore, your benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure) (64495 X 2) and the anesthesia (01992 X 2). 
 
You asked the Plan to pre-approve the services. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee's records show 
you do not have documentation for why you need sedation, nor a three-level procedure. On appeal, your 
provider even notes that the two levels already approved by the Plan will suffice for your diagnostic MBB 
session. 
 
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 services. Our physician reviewer 
found the enrollee does not have any factors (e.g., morbid obesity, obstructive sleep apnea (OSA), spasticity, 
etc.) that supports the need for a second provider. The LCD has a utilization limit of two (2) levels per session. 
There is no documentation that supports exceeding this limit. The requested services are not medically 
reasonable and necessary. Furthermore, the anesthesia (01992 x 2) is not approved because the LCD states that 
general anesthesia is considered not medically reasonable and necessary for facet joint interventions. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint 
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any 
additional level(s) (List separately in addition to code for primary procedure) (64495 X 2) and the anesthesia 
(01992 X 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 13, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service September 
25, 2022, to September 26, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the appropriate documentation was received. 
The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 93306. 
 
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 93042 is a column II code to column I code 93306. The code at issue 
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 
93042 billed for date of service September 25, 2022, to September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87641, 87653 and 87798 
billed for date of service July 21, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87641, 87653 and 87798. You say that these 
services were reported correctly and are supported in the medical record. The Plan denied your request. The 
Plan says these services are not supported for separate payment, as they are included in other services billed. 
 
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 87481, 87640, 87641, 87653 and 87798 is a column II code to 
column I code 87801; however, 87481, 87640, 87641, 87653 and 87798 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87481, 87640, 87641, 87653 and 87798. 
Our reviewer says that the 59 modifier is not supported for use with these codes in this case. Our reviewer 
found these services are not supported as separate and distinct from code 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87640, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87640, 87641, 87653 and 
87798 billed for date of service July 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies (A0382) provided on July 29, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that this claim was denied in error. The Plan 
denied your request. The Plan says the payment for these services is included in the general ambulance service 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies (A0382) provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341). The Plan denied your request. The Plan says that the requested service is not a medical necessity. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) 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 periodontal scaling and root planing 
- four or more teeth per quadrant (D4341). Our reviewer says that the periodontal scaling and root planing is 
medically necessary. Our physician reviewer found the documentation indicates that there is evidence of 
pathological periodontal pocketing (4-6mm) in four quadrants with evidence of bone loss. Periodontal scaling 
and root planing is medically reasonable and necessary to treat the patient's periodontal disease. 
 
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 periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root 
planing - four or more teeth per quadrant (D4341).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty cable (L6660) and terminal device, hook 
or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined (L6721). 
 
You asked the Plan to pre-approve a heavy-duty cable and terminal device. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items 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 a heavy-duty cable and terminal device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a left above elbow amputation. The documentation 
shows that the requested items exceed the enrollee's medical needs. The documentation does not reveal that the 
patient's activities require a heavy-duty cable or heavy-duty hand. Therefore, the enrollee does not meet criteria 
for the requested items. 
 
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 heavy-duty cable and terminal device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty cable (L6660) and terminal device, hook or 
hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined (L6721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940) provided on 
June 21, 2022 and October 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided do not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that the 
services provided do not meet criteria for coverage.  Our physician reviewer found that in this case, the record indicates that you have occipital, cervical, and 
thoracic subluxation. The records provided indicate that the visits in question provided maintenance therapy. 
Therefore, the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. 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 the chiropractic manipulative treatments (98940) provided on June 21, 2022 and October 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity, below knee/above knee, 
custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism (L5683) custom shaped protective cover, 
below knee (L5704) and addition, endoskeletal system, below knee, alignable system (L5910). 
 
You asked the Plan to pre-approve the replacement prosthetic parts. You say that you are appealing the 
decision not to approve code L5683 for the custom gel liner. The provided documentation will prove necessity. 
The Plan denied your request. The Plan says the requested items is not covered by Medicare or the Plan. The 
records do not show why the parts of the prosthesis are needed. The request for the custom socket insert and an 
alignable system cannot be approved at this time. 
 
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 replacement prosthetic parts. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested items exceed the enrollee's medical need as the 
documentation does not reveal that the current L5910 is beyond repair. The L5683 custom shaped protective 
cover, below knee exceeds the enrollee's medical needs per the Social Security Act, Section 1862 (a)1(A) and 
the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member and per Local Coverage Determination (LCD) Lower Limb Prostheses L33787. LCD L33787 states no 
more than two socket inserts are allowed for a given prosthesis. The documentation indicates that the enrollee 
was already approved for 2 sockets and there are no extenuating factors on physician notes that indicate a need 
for a third socket. 
 
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 replacement prosthetic parts have not been met. Therefore, we decided that 
the Plan does not have to pre-approve addition to lower extremity, below knee/above knee, custom fabricated 
socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use 
with or without locking mechanism (L5683) custom shaped protective cover, below knee (L5704) and addition, 
endoskeletal system, below knee, alignable system (L5910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for creatinine, blood (82565) and specific gravity (liquid weight) 
measurement (84315) provided May 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you do not personally see the patients and 
are dependent on receiving patient information from the ordering provider. The Plan denied your request. The 
Plan says these services are not covered under the Plan. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the records do not support that the criteria has been met. Our reviewer found for CPT code 82565 the 
laboratory report does not include blood test creatinine and therefore cannot be verified.  Provider tested urine 
sample. There is a more appropriate code to report for service provided. For CPT code 84315, the laboratory 
report does not include specific gravity (except urine) and therefore cannot be verified. The laboratory report 
documents urine test was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for creatinine, blood (82565) and specific gravity (liquid weight) measurement (84315) 
provided May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5211) and a lower partial denture 
(D5212). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the requested items are not covered under your 
supplemental policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that an upper partial denture and a lower partial 
denture are not covered under your supplemental dental policy. However, the Plan did not provide the 2023 
Evidence of Coverage contract for the year in which the request was made for these dental items. Therefore, we 
are unable to determine the allowable coverage for the requested dental items. The Plan has not substantiated 
their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-approve an 
upper partial denture (D5211) and a lower partial denture (D5212).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99221 provided on June 25, 2022. 
 
You asked the Plan to pay for code 99221. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the code billed 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 99221 is Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and 
Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission 
are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99221. Our reviewer says that code 99221 is supported 
in the documentation. Our reviewer found the enrollee has a medical history including lymphedema and 
osteopenia who was admitted to the hospital with acute kidney injury, dehydration, a urinary tract infection and 
a left ureteral stone. The enrollee was seen and evaluated on and noted to be stable. The documentation 
supports there was a detailed or comprehensive history, a detailed or comprehensive exam, and medical 
decision making that is straightforward or of low complexity. Therefore, the documentation does support code 
99221. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99221 have been met. Therefore, we decided that the Plan has to pay for 
code 99221 provided on June 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.