Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44140 and 49084 rendered on September 
10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service is not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 44140: 
 
Colectomy, partial; with anastomosis  
CPT 49084: 
 
Peritoneal lavage, including imaging guidance, when performed 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
contain documentation of the CPT codes in question. In terms of CPT 44140, the documentation states that a 
colectomy was performed; however, the anastamosis is not mentioned in the operative report. The required 
components of 44140 are not present, therefore, this code is not supported. Additionally, CPT code 49084 is 
not supported. According to CPT guidelines, a peritoneal lavage is performed by inserting a catheter into the 
abdomen, fluids are infused, and the fluids are then aspirated for diagnostic testing. The operative report 
describes flushing the abdominal cavity with saline. This does not fit the description of 49084, therefore, this 
code is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 44140 and 49084 rendered on September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic tooth #'s 23, 24, and 25 
(D2740) provided on December 15, 2022. 
 
You asked the Plan to pay for the complete denture - maxillary (D5110), and crowns - porcelain/ceramic 
(D2740). You say that you wanted only the work done that would be covered by your allowance.  The Plan denied your request. The Plan says your benefit for the crowns - porcelain/ceramic $1,150 dollar limit 
was met. 
 
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 crowns  porcelain/ceramic was exhausted on date of service December 15, 2022. 
The total amount of the claim was $5,735.00. The Plan paid $2,600.00 of the claim ($5,735.00 - $2,600.00 = 
$3,315.00). This includes the $1,150.00 dental allowance and the full cost of the denture. This is the amount 
that was not covered by the Plan and is your responsibility, $3,135.00. This amount is denied for the calendar 
year maximum has been reached. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain/ceramic tooth #'s 23, 24, and 25 (D2740) provided on December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is non-covered because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is not 
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99238. 
 
 
 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 99232 
is a column II code to column I code 99238 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the primary care provider office visit 
provided on January 11, 2023. 
 
You asked the Plan to waive the copayments for the primary care provider office visit. You say that you did not 
receive an EKG. The Plan denied your request. The Plan says this cost sharing was charged 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 $15 
copayment for in-network primary care provider office visits.  
 
You have been asked to pay a $15 copayment for the primary care provider office visit. This item/service falls 
within the physician/practitioner services 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 copayments 
for the primary care provider office visit provided on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism (E0627) and recliner (E1399). 
 
You asked the Plan to pre-approve the seat lift mechanism and recliner. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary.  
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. Recliner chairs are not covered as they do not primarily serve a 
medical purpose. 
 
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 seat lift mechanism and recliner. 
Our reviewer says that you do not need this item. Our physician reviewer found the provided records do not 
specifically document severe arthritis of the hip or a neuromuscular disease, or that the seat lift is likely to 
affect improvement in the patient's condition or arrest or retard deterioration in the patient's condition. The 
records also do not document a seat lift in the treating practitioner's treatment plan. 
 
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 seat lift mechanism and recliner have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the seat lift mechanism (E0627) and recliner (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite-one surface, posterior (D2391)
and a resin-based composite-two surfaces, anterior (D2331) for teeth numbers 9 and 31.
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the
Plan's denial. 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record
shows your benefit for the requested services were exhausted on date of service September 5, 2019, and
September 20, 2020.
Therefore, we decided that the Plan does not have to pre-approve a resin-based composite-one surface, posterior (D2391) and a resin-based composite-two surfaces, anterior (D2331) for teeth numbers 9 and 31.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve breast MRI. You say that this procedure is very important because you are a 
cancer survivor. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that breast MRI may be covered if certain criteria are 
met. 
 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 breast MRI. Our reviewer says that you 
do not meet criteria for the requested breast MRI. Our physician reviewer found you have a history of treated 
breast cancer in 2015. There has been no physical sign of recurrence. Your last mammogram was in 2020 and 
prior breast MRI was negative on September 22, 2020. There is a plan for bilateral breast ultrasound and 
mammography which have not yet been done as of the encounter of January 6, 2023. The breast parenchyma 
has been described as type 2 meaning scattered fibroglandular elements meaning no evidence of extremely 
dense tissue which may limit mammography. There is no calculation of lifetime risk of breast cancer using the 
Gail model or the Tyrer-Cuzick model to justify screening MRI. Absent all of these items the medical necessity 
of the requested breast MRI has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast magnetic resonance imaging (MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image (D0350), oral hygiene 
instructions (D1330), risk assessment and documentation(D0602), house/extended care facility call (D9410) 
and adjunctive pre-diagnostic test (D0431). You also asked for intraoral - complete series of radiographic 
images (D0210) and comprehensive oral evaluation (D0150) provided on December 6, 2022. 
 
 You asked the Plan to pay for imaging, oral hygiene, risk assessment, house call, testing and an exam.. You say 
that this should be covered. The Plan denied your request. The Plan says these are not covered services and you 
have exhausted your benefit for intraoral - complete series of radiographic images and comprehensive oral 
evaluation. 
 
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 2D 
oral/facial photographic image (D0350), oral hygiene instructions (D1330), risk assessment and 
documentation(D0602), house/extended care facility call (D9410) and adjunctive pre-diagnostic test (D0431). 
You also asked for intraoral - complete series of radiographic images (D0210) and comprehensive oral 
evaluation (D0150) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement, primary and permanent teeth (D3221), 
pulp vitality tests (D0460), and cone beam CT capture and interpretation with limited field of view  less than 
one whole jaw (D0364) provided on January 26, 2023, and February 2, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D3221, D0460, and D0364. You say 
that you are concerned about the amount that was charged for the limited amount of work provided. You also 
say that it was only for removing a metal post, replacing it with a new post then put a temporary filling on it for 
$1,356. The Plan denied your request. The Plan says these services are not listed on the covered services dental 
chart. 
 
 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 pulpal 
debridement, primary and permanent teeth (D3221), pulp vitality tests (D0460), and cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364) provided on January 26, 2023, and 
February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655) and insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct or inductive coupling (63685). 
 
You asked the Plan to pre-approve the laminectomy and insertion or replacement of spinal neurostimulator 
pulse generator or receiver. You say that the services are medically necessary. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the device is a central nervous system stimulator 
being used to treat chronic intractable pain and all of the following must be met, A. The implantation of the 
stimulator is used only as a late resort, if not last resort, for patients with chronic intractable pain. B. Other 
treatments (medications, surgical, physical, or mental health therapy) have been tried and did not help your 
symptoms, or these are not suitable. C. The patient must have had screening (a physical and mental health 
evaluation) and a diagnosis by a team from different areas of medicine.  
 
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 laminectomy and insertion or 
replacement of spinal neurostimulator pulse generator or receiver. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found detailed documentation is not evident regarding a 
psychological evaluation having been completed clearing her for this procedure. Moreover, there is no 
documentation of a spinal cord stimulator trial having been completed with benefits. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 laminectomy and insertion or replacement of spinal neurostimulator pulse 
generator or receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural (63655) and insertion or 
replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (63685).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthofix trinity elite allograft. 
 
You asked the Plan to pre-approve Orthofix trinity elite allograft. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Orthofix trinity elite allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Ortho trinity allograft is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthofix trinity elite allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Orthofix trinity elite allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a lightweight portable motorized/power 
wheelchair purchased on November 23, 2022. 
 
You asked the Plan to reimburse you for a lightweight portable motorized/power wheelchair. You say that your 
provider recommended this company. The Plan denied your request. The Plan says the provider is not enrolled 
in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a lightweight portable motorized/power wheelchair have not been met. This provider is not 
enrolled in Medicare so is not payable. Therefore, we decided that the Plan does not have to reimburse you for 
a lightweight portable motorized/power wheelchair purchased on November 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of trastuzumab-DTTB. 
 You asked the Plan to pre-approve trastuzumab-DTTB. You say that the enrollee will die without 
chemotherapy. The Plan denied your request. The Plan says the Plan requires a trial of Kanjinti and Trazimera 
before it will approve trastuzumab-DTTB. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 trastuzumab-DTTB. Our reviewer says 
that the enrollee does not meet criteria for a step therapy exception for trastuzumab-DTTB. Our physician 
reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Kanjinti and Trazimera. The 
record does not show that these drugs would likely be less effective and/or have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trastuzumab-DTTB have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of trastuzumab-DTTB.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic pill dispenser. 
 
You asked the Plan to pre-approve an automatic pill dispenser. You say that this should be covered. The Plan 
denied your request. The Plan says this is not covered as it does not primarily serve a medical purpose. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an automatic pill dispenser.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
December 7, 2021, through December 31, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on December 7, 2021, through December 31, 2021.