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

 
We decided that the Plan does not have to pay for the periapical each additional x-ray (D0230 x 7) provided on 
May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would not have had these x-rays taken if 
you were informed that they would not be covered. 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 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 your benefit for the requested item or service was exhausted on date of service May 24, 2023. Therefore, 
we decided that the Plan does not have to pay for the periapical each additional x-ray (D0230 x 7) provided on 
May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that your doctor advised you to appeal this 
denial. The Plan denied your request. The Plan says there is no documentation that there is a physiologic 
functional impairment that will be addressed by the surgery. 
 
The Plan follows Medicare rules. Medicare rules say that a panniculectomy will be considered medically 
necessary when the medical records document that the panniculus causes chronic intertrigo over a period of 3 
months. 
 
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 panniculectomy. Our reviewer says 
that the request for a panniculectomy is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a pannus that does not extend below the level of the pubis. The record provided 
does not document the presence of functional impairment or the existence of chronic interigo refractory to 
conservative therapy over a period of three months. Therefore, the reviewer found that the request for a panniculectomy is not medically reasonable or necessary. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 30, 2023, billed with 
procedure code 28430-54-RT. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 28430-54-RT is closed treatment of talus fracture; 
without manipulation. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found the medical record includes sufficient 
documentation to support closed fracture treatment. Procedure of immobilizing fracture was not included in the 
documentation and therefore cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 30, 2023, billed with procedure code 
28430-54-RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says facet joint 
injections 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that there is no documentation 
as to why RFA of the medial branches is not indicated. Also, there is no documentation of a pseudoarthrosis or 
an implanted electrical device. Therefore, the request is not medically reasonable and necessary. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that Skilled Nursing Facility continuation is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not require daily 
skilled nursing services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth #15. 
 
You asked the Plan to pre-approve the dental service. You say that there is decay and a hole on the backside of 
the tooth. The Plan denied your request. The Plan says that the denial of authorization for the crown is correct, 
because the x-rays of the tooth do not show that there is a cavity under the old cap. 
 
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 did not collect clear dental x-rays from their participating 
provider who ordered the requested crown. Without this necessary documentation we are unable to make a 
determination as to whether the enrollee has met the criteria for coverage for the crown (D2750) for tooth #15. 
Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth #15.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options and 
expandable controller (E0955, E0956, E1007, E1012, E1028, E2209, E2311, E2313, E2361, E2377, E2620, 
E2622, K0108, K0861). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and expandable 
controller. You say that this power wheelchair is medically necessary. The Plan denied your request. The Plan 
says that the enrollee's needs can be met by a less complex power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when the beneficiary meets coverage criteria for a group 3 power wheelchair and the 
beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being used on 
the wheelchair, or, the beneficiary uses a ventilator which is mounted on the wheelchair.  
 
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 group 3 power wheelchair with 
multiple power options and expandable controller.  Our reviewer says that the requested power wheelchair and accessories are medically necessary. Our physician 
reviewer found the records show that the enrollee cannot operate a power scooter due to impaired sitting 
balance and ability to transfer. The enrollee requires a power wheelchair for mobility and accomplishing their 
daily activities. The patient has left sided hemiparesis and is unable to functionally perform pressure relief and 
therefore requires power tilt and recline. She is also noted to have spasticity and requires a power articulating 
foot platform for the spasticity and positioning of her lower extremities. Given her complex seating needs, the 
enrollee requires a group 3 power wheelchair with the requested power components and upgraded electronics. 
 
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 group 3 power wheelchair with multiple power options and expandable 
controller have been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair 
with multiple power options and expandable controller (E0955, E0956, E1007, E1012, E1028, E2209, E2311, 
E2313, E2361, E2377, E2620, E2622, K0108, K0861).  
 
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 walker (E0149) and seat attachment, 
walker (E0156). 
 
You asked the Plan to pre-approve the heavy-duty walker. You say the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. The records show that the enrollee weighs 269 pounds and does not 
meet the weight requirement of more than 300 pounds for the requested walker. Based on this information, we 
decided that Medicare rules for coverage of the heavy-duty walker have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy-duty walker (E0149) and seat attachment, walker (E0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
and topical application of fluoride varnish (D1206) provided on June 14, 2023. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image and topical application of 
fluoride varnish. You say that you believe the denial is tied to a form you were supposed to fill out prior to your 
appointment. The Plan denied your request. The Plan says if a procedure is not on the covered code list it is not 
a covered benefit 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (D0220), and topical application of fluoride varnish (D1206) provided on 
June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care to regain strength and mobility for 
daily living. The Plan denied your request. The Plan says your condition does not meet the criteria for an IRF 
admission.  
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  IV sedation anesthesia (D9239 & D9243) provided on June 
22, 2023. 
 
You asked the Plan to pay for IV sedation anesthesia. You say that due to your mental illness, you would not 
have been able to go through the surgery with only a local anesthesia. The Plan denied your request. The Plan 
says this is not a covered service. 
 
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  IV 
sedation anesthesia (D9239 & D9243) provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutments  includes modification and 
placement (D6056) provided on March 29, 2023. 
 
You asked the Plan to pay for the prefabricated abutments. You say that you do not agree with the denial of 
dental services. The Plan denied your request. The Plan says this service is excluded from coverage 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated 
abutments  includes modification and placement (D6056) provided on March 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97140, 97110) provided on April 
3, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that S39.012D has an Excludes1 note in relation to M54.50. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the physical therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (97140, 97110) provided on April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is unable to transfer to a 
lower level of care due to facility capabilities and risk for complications. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has ongoing medical issues and still requires acute care services 
before transitioning to a lower level of care. The medical records do not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH facility.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (20930). 
 
You asked the Plan to pre-approve a bone graft enhancer. You say that you have been waiting five years for 
this surgery and have severe pain in your back to the point that you cannot walk or sleep. You are at risk of 
becoming paralyzed if not corrected. The Plan denied your request. The Plan says the requested procedure is 
unproven and 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 bone graft enhancer. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found osteopromotive allograft is experimental and investigational in spine surgery. An 
Iliac crest autograft is the gold standard. 
 
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 bone graft enhancer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft, morselized, or placement of osteopromotive material, for spine 
surgery only (20930).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided on November 7, 2022, to 
January 6, 2023. 
 
You asked the Plan to pay for the home health aide services. You say that you feel you were misled by the 
provider and you did not realize that this service was not covered by the insurance. You also say that this 
provider was the only company that was readily available. The Plan denied your request. The Plan says the 
records provided (washing dishes, sweeping, laundry, etc.) were all custodial care services and are not a 
Medicare 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 the home health aide 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 pay for home 
health aide services provided on November 7, 2022, to January 6, 2023.  
 
Your complaint about being misled by the provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on October 14, 2022, through November 3, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on October 14, 2022, 
through November 3, 2022.