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

 
We decided that the Plan does not have to pre-approve positioning wheelchair back cushion and synergy 
seating frame. 
 
You asked the Plan to pre-approve positioning wheelchair back cushion and synergy seating frame. You say 
that you disagree with the Plan's denial The Plan denied your request. The Plan says you do not meet criteria 
for the requested items. 
 
The Plan follows Medicare rules. Medicare rules say that positioning wheelchair back cushions are only 
covered for certain diagnosis. Any diagnosis not listed in the criteria is not covered. The rules also say that the 
use of code K0108 or any other code to separately bill for added components such as the foam blocks, gel 
packs, air cells, or equivalent material is incorrect coding and therefore, 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 positioning wheelchair back cushion 
and synergy seating frame. Our reviewer says that the documentation does not support that the requested items 
are medically reasonable or necessary. Our physician reviewer found you require a wheelchair for mobility. 
The documentation does not support that you have a diagnosis from either group 2 or group 3 of the wheelchair 
seating criteria. In addition, use of code K0108 or any other code to separately bill for added components such 
as the foam blocks, gel packs, air cells, or equivalent material is incorrect coding. This means that you do 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 positioning wheelchair back cushion and synergy seating frame have not been 
met. Therefore, we decided that the Plan does not have to pre-approve positioning wheelchair back cushion and 
synergy seating frame.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and you are an extremely high risk for 
a fall. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit 
from additional multiple therapies, including physical and occupational therapy, the documentation does not 
reveal that you require this therapy or can tolerate this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy performed on April 15, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that there should be no copayment for 
a preventative colonoscopy. The Plan denied your request. The Plan says the cost share has been applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $300 for 
ambulatory surgical center visits.  
 
You have been asked to pay $300 for a colonoscopy. A colonoscopy falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. Records submitted support this procedure was intended for diagnostic care. Therefore, this was not a 
preventative visit. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy performed on 
April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns - porcelain/ceramic (D6740), pontic - 
porcelain/ceramic (D6245), custom fabricated abutment  includes placement (D6057) and abutment supported 
porcelain fused to metal crown (predominantly base metal) (D6060). 
 
You asked the Plan to pre-approve a retainer crowns, pontic, custom fabricated abutment and abutment 
supported crown. You say that you need these services. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245), custom fabricated abutment 
 includes placement (D6057) and abutment supported porcelain fused to metal crown (predominantly base 
metal) (D6060).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an onlay (D2644), indirect pulp cap (D3120), and 
gingivectomy or gingivoplasty (D4212). 
 
You asked the Plan to pre-approve the onlay, indirect pulp cap, and gingivectomy or gingivoplasty. You say 
that you would like to know why these services have been denied, because they are less expensive than the 
crown which was approved. The Plan denied your request. The Plan says your plan does not cover these 
procedures. 
 
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 
onlay (D2644), indirect pulp cap (D3120), and gingivectomy or gingivoplasty (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate partial lower denture (D5222). 
 
You asked the Plan to pre-approve an immediate denture. You say that this service should be covered because 
you will otherwise be without teeth for several weeks. The Plan denied your request. The Plan says this service 
is 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 an 
immediate partial lower denture (D5222).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87641, 88305, 88312) provided March 
17, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of lab services (87798, 87641, 88305, 
88312) provided March 17, 2021. have been met. The records did not include lab results or clinical 
documentation to support the codes billed. Therefore, we decided that the Plan does not have to pay for lab 
services (87798, 87641, 88305, 88312) provided March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 30, 2022, billed with 
codes 81317, 81292, 81298, 81295 and 81300. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 30, 2022, billed with codes 81317, 81292, 81298, 81295 and 81300.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to crown dental procedure 
(D2952) 
 
You asked the Plan to pre-approve the post and core in addition to crown dental procedure. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post 
and core in addition to crown dental procedure (D2952)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy performed February 21, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says the copayment has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $425 
copayment per visit for outpatient surgery provided at hospital outpatient facilities. 
 
 
 
 
 
 
 You have been asked to pay $425 for a colonoscopy. A colonoscopy falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a colonoscopy performed February 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services (CPT code(s): G0152 x20, 
G0151 x21, and G0299 x1). 
 
You asked the Plan to pre-approve the home health services. You say that the home health services are 
necessary. The Plan denied your request. The Plan says the home health services are not necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our physician 
reviewer found the provided records do not document any acute or unstable medical conditions or changes in 
medication or treatment which would necessitate any further skilled nursing or therapy visits beyond what have 
already been approved. Records document the enrollee has been educated on her disease process and 
medications. Records do not document the need for intravenous medications, new tube feeding, or ostomy care 
or daily complex wound care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services (CPT code(s): G0152 x20, G0151 x21, and G0299 x1).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the requested manual wheelchair is 
medically necessary due to other acute post procedural pain. The Plan denied your request. The Plan says this 
request cannot be considered reasonable and 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 manual wheelchair. 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 manual wheelchair at issue in this case meets 
Medicare criteria. Provided records do not document that the enrollee has a personal mobility deficit that 
impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and 
bathing in customary locations within the home. Records provide no documentation that the enrollee's mobility 
deficit cannot be helped by the use of a walker or cane. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker with seat. 
 
You asked the Plan to pre-approve a heavy-duty walker with seat. You say that this is necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that that a heavy-duty walker is covered for 
beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds 
 
We looked at the file and Medicare rules. In this case, the medical records provided do not indicate that you 
weigh more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of a 
heavy-duty walker with seat have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty walker with seat.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement cardioverter-defibrillator (CPT code(s): 
C1777, 33241, C1721, 33249). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
they do not have indication of end of battery life, elective replacement indicator (ERI), or device/lead 
malfunction. 
 
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 surgical services. Our physician 
reviewer found at this time replacing the single-chamber ICD with a dual-chamber ICD would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 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 surgical services have not been met. Therefore, we decided that the Plan does not have to pre-
approve the replacement cardioverter-defibrillator (CPT code(s): C1777, 33241, C1721, 33249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140) to be rendered by an oral 
surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that you are covered for one tooth extraction per 
year, but do not understand why this service was not approved. The Plan denied your request. The Plan says the 
supplemental dental services benefit of your contract only provides coverage for dental services when they are 
performed by a participating general dentist. The Plan also says that dental services performed by an oral 
surgeon 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 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 
covered when they are provided by anyone other than a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve an extraction (D7140) to be rendered by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) to be 
provided by a network provider. 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that you need the 
procedure to correct your jawbone in order for your partial to fit properly. The Plan denied your request. The 
Plan says the service is 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 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 
removal of torus mandibularis (D7473) to be provided by a network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deluxe feature on an upright walker A9270). 
 
You asked the Plan to pre-approve a deluxe feature on an upright walker. You say that you have a history of 
transient ischemic attack and cerebral infarction, radiculopathy, cervical and lumbar region, and obesity. This 
request is medically necessary for your condition. The Plan denied your request. The Plan says equipment 
which basically serves comfort or convenience functions does not constitute as medical equipment, therefore, 
the requested item is not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that a deluxe feature on an upright walker is not 
covered.  
 
The records show that you were approved and provided with a standard walker by the Plan. The requested 
walker is considered a convenience item, neither the Plan nor Medicare offers coverage for this item. 
Therefore, we decided that the Plan does not have to pre-approve a deluxe feature on an upright walker 
A9270).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary because the patient's 
chance to return home and remain living at home will be significantly reduced if her opportunity to participate 
in acute rehab is denied. The Plan denied your request. The Plan says that IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found Hip fracture is an IRF compliant diagnosis. The patient has multiple active comorbidities and will 
continue to require close medical supervision on an inpatient basis. Evaluating therapists (physical and 
occupational therapy) both recommend intense therapy and that patient will tolerate 3 hours of therapy per day, 
thus IRF criteria has been 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.