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

 
We decided that the Plan has to pre-approve the prostheses identified with codes L5828, L5845, L5848, L5856, 
and L5987. 
 You asked the Plan to pre-approve the prostheses identified with codes L5828, L5845, L5848, L5856, and 
L5987. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prostheses are covered for certain indications. 
Microprocessor knees are covered for enrollees whose functional level is 3 or above. 
 
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 prostheses identified with codes 
L5828, L5845, L5848, L5856, and L5987. Our reviewer says that the documentation supports that the 
requested items are medically reasonable and necessary. Our physician reviewer found you underwent a left 
transfemoral amputation in November of 2020 after complications due to a total knee arthroplasty.  
The documentation supports that you have been using your preparatory prosthesis. The documentation shows 
that you are very active and frequently walk on uneven terrain and performs manual labor. You are rated as a 
K3 level ambulator. A clinical progress note dated May 2, 2022 indicates that you are a high level ambulator 
who walks on uneven terrain as well as in the community. Your residual limb has matured, and you are 
working with outpatient physical therapy. It also indicates that you have fallen several times with your standard 
prosthesis and broken your left hip from a fall. The requested microprocessor knee is covered for enrollees 
whose functional level is 3 or above. Additionally, it is a safer option than the current hydraulic knee given the 
documented falls that you have experienced, once of which resulted in a hip fracture. Therefore, you 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 the prostheses identified with codes L5828, L5845, L5848, L5856, and L5987 
have been met. Therefore, we decided that the Plan has to pre-approve the prostheses identified with codes 
L5828, L5845, L5848, L5856, and L5987.  
 
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 an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), an expandable controller harness (E2313) and an 
expandable controller (E2377). 
 
 
 
 You asked the Plan to pre-approve power wheelchair accessories. You say that you need a chair with multiple 
seating options (tilt and recline) as was recommended by the physical therapist and seating specialist. The 
power tilt function alone will not meet your pressure relief needs. The Plan denied your request. The Plan says 
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. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), an expandable controller harness (E2313) and an 
expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87491, 87493, 87500, 87505, 87640, 87641) 
billed for date of service September 28, 2021. 
 
You asked the Plan to pay for lab services billed for September 28, 2021. You say that these services were 
ordered by a physician and were reported appropriately. The Plan denied your request. The Plan says these 
services are not supported as billed, and the 59 modifier is not supported for separate payment for those 
services which are included in other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that, with few exceptions, the date of service which should be billed for laboratory services 
is the date that the specimen was collected. 
 
We find that lab services billed for date of service September 28, 2021, are not supported in the medical record. 
Specifically, the record shows that the specimen was collected on September 23, 2021, in an office setting. This 
means that none of the exceptions to the general rule apply in this case. No laboratory report for the date of 
service in question was provided for review, and as such, these services cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of lab services billed for September 28, 2021, have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87491, 87493, 87500, 
87505, 87640, 87641) billed for date of service September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2021, billed with 
codes 81408, 81249, 81230, 81291, 81226, 81225, 81241, 81240 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 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 
August 19, 2021, billed with codes 81408, 81249, 81230, 81291, 81226, 81225, 81241, 81240 and 81335.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp cap (D3120) and an unspecified preventive procedure 
(D1999 x2) provided from December 7, 2021, through February 15, 2022. 
 
You asked the Plan to pay for a pulp cap and an unspecified preventive procedure. You say that the services 
should be covered. The Plan denied your request. The Plan says the services at issue are not covered 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 pay for a pulp cap 
(D3120) and an unspecified preventive procedure (D1999 x2) provided from December 7, 2021, through 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 25, 2021, billed with 
codes 81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that these charges should be covered. The Plan 
denied your request. The Plan says the lab should only report one code for these services. 
 
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 
June 25, 2021, billed with codes 81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291, and 81240.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services billed as 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, 81311 and 81321. 
 
You asked the Plan to pay for the genetic testing services as billed. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says that there is information 
that indicates the testing was not ordered by the provider in question. 
 
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. In this case, the Plan has denied payment by stating that the providers office 
confirmed testing was not ordered. This stands in opposition to the signed test requisition form listed in the 
case file. There is no indication that this signature does not belong to the ordering provider. In addition, other 
codes from this genetic testing panel were approved for coverage which would indicate the services were 
ordered by the provider in question and are indeed payable. Therefore, we decided that the Plan has to pay for 
the genetic testing services billed as 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311 and 
81321.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical 
radiographic images (D0220, D0230), bite wing radiographic images (D0274), and teeth cleaning (D1110) 
provided on April 12, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
   
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), intraoral periapical radiographic images (D0220, D0230), bite 
wing radiographic images (D0274), and teeth cleaning (D1110) provided on April 12, 2022, by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placements of intra-socket biological dressings (D7922) 
provided on May 5, 2022. 
 
You asked the Plan to pay for the placements of intra-socket biological dressings. You say that you had this 
procedure done because it was previously approved by the Plan. The Plan denied your request. The Plan says 
this service is not a covered benefit. The Plan also say that there was no approval, Letter of Agreement, or 
Single Case Agreement for the two placements of intra-socket biological dressings (D7922 x2). 
 
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 pay for the 
placements of intra-socket biological dressings (D7922) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066) and an abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve an implant supported crown and an abutment supported porcelain/ceramic 
crown. You say that you need authorization for the implant services. 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 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 crown (D6066) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2) and two abutment supported porcelain fused to metal crowns (D6060 x2). 
 
You asked the Plan to pre-approve the endosteal implants and abutment supported porcelain fused to metal 
crowns. You say that you were told an implant and bridge are similar in price. You also say that an implant is 
better than a bridge. 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 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2) and two abutment supported porcelain 
fused to metal crowns (D6060 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fifth unit of an antibody stain procedure (88342-59) 
provided on September 7, 2021. 
 
You asked the Plan to pay for a fifth unit of an antibody stain procedure. You say that this was billed correctly. 
The Plan denied your request. The Plan says this exceeds MUE. 
 
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 88342 is immunohistochemistry or 
immunocytochemistry, per specimen; initial single antibody stain procedure. 
 
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 an antibody stain procedure. Our reviewer says that this is 
not supported in the records. Our reviewer found there is a more appropriate procedure code that can be billed 
for this procedure. The MUE for 88342 is 4, and modifier -59 is not appropriate to bypass the MUE. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an antibody stain procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for a fifth unit of an antibody stain procedure (88342-59) provided on September 7, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain fused to predominantly base metal on 
tooth #6 (D2751) and prefabricated post and core in addition to crown on tooth #6 (D2954). 
 
You asked the Plan to pre-approve the crown and prefabricated post and core. You say that it is urgent for your 
to get the implant after your root canal. The Plan denied your request. The Plan says that 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 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 
crown-porcelain fused to predominantly base metal on tooth #6 (D2751) and prefabricated post and core in 
addition to crown on tooth #6 (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #7, 8, 9, and 10 (D2950). 
 
You asked the Plan to pre-approve core build up. You say that these services are medically necessary. The Plan 
denied your request. The Plan says core build up (D2950) is not covered by the enrollees supplemental 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 core 
build up on tooth #7, 8, 9, and 10 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve a prefabricated abutment and abutment supported porcelain/ceramic crown. 
You say that this crown will allow you to chew on that part. The Plan denied your request. The Plan says these 
services are 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgraded electronic connection system. 
 
You asked the Plan to pre-approve upgraded electronics. You say that this equipment is medically necessary 
for the enrollee's condition in operating the wheelchair. The Plan denied your request. The Plan says there is no medical need for the upgraded electronics because there is no medical need to control 
power options through joystick. 
 
The Plan follows Medicare rules. Medicare rules say that the upgraded electronics are subject to the criteria 
listed in the Medicare rule section regarding electronic components. 
 
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 upgraded electronics. Our reviewer says 
that the requested electronic equipment is not medically reasonable and necessary. Our physician reviewer 
found the enrollee has adequate strength to use standard power controls. In this case, there is no evidence of a 
need for expanded controls. Per Medicare rules delineating DME coverage, the additional electronics are not 
necessary to meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upgraded electronic connection system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the direct therapeutic activity (97530), and self-care or home 
management training (97585) provided on February 25, 2021. 
 
You asked the Plan to pay for the rehabilitation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the rehabilitation services was not filed until March 21, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the direct therapeutic activity (97530), and self-care or home 
management training (97585) provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on October 3, 
2021, to December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that each claim meets Medicare 
criteria for coverage. You say you could not have reasonably known prior authorization was required. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
automatic external defibrillator. We found no exception that would require the Plan to pay for the automatic 
external defibrillator. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator 
provided on October 3, 2021, to December 3, 2021, by an out-of-network (OON) provider.