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

 
We decided that the Plan does not have to pre-approve clinical crown lengthening - hard tissue (D4249). 
 
You asked the Plan to pre-approve clinical crown lengthening - hard tissue (D4249). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the criteria for this services has 
not been 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. The Plan covers clinical crown 
lengthening - hard tissue (D4249) when the services are medically necessary and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve clinical crown lengthening - hard tissue 
(D4249). Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
crown of the tooth appears adequate. Our physician reviewer also found that 4 to 5 millimeter periodontal 
pockets were recorded in this area. Our physician reviewer also found that this is not treated by crown 
lengthening procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of clinical crown lengthening - hard tissue (D4249) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve clinical crown lengthening - hard tissue (D4249).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there were/are multiple plausible pathologic sources of significant pain generation. 
The non-radiating midline back pain, the noted pain-aggravating factors (looking around, looking down, 
looking up, lifting, bending, standing, stretching, twisting, and walking), pain-relieving factors (opioid 
medications, chiropractic treatment, massage, physical therapy, heat/ice, and rest), and limited exam were/are 
all non-specific to any pathologic entities. Moreover, detailed documentation is not evident regarding a failure 
to respond to greater than or equal to 6 months of non-surgical management. Therefore, the enrollee does not 
meet the coverage criteria. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that the item should be covered. The Plan denied 
your request. The Plan says this item 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 a walk-in shower.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show osteoporosis, or failed conservative management of the 
vertebral fracture. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding the worsening of pain. Additionally, there 
is no documentation of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. Moreover, there is CT (computed tomography) 
corroboration of other plausible causes of pain. Therefore, the enrollee does not meet the criteria for this 
request. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Epifix skin graft (Q4186, 15271). 
 
You asked the Plan to pre-approve Epifix. You say that the requested service is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested service is 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 Epifix. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested service is not medically necessary based on the community standards 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 Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an Epifix skin graft (Q4186, 15271).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve follow-up sleep studies (codes 95810 and 95811). 
 
You asked the Plan to pre-approve follow-up sleep studies. You say that you would like your machine to be 
replaced because you have had it for 20 years. The Plan denied your request. The Plan says the request is not 
medically necessary because you have had a good response with CPAP and no settings will need to change 
with a new CPAP machine.  
 
The Plan follows Medicare rules. Medicare rules say that a follow-up PSG may be indicated under the 
circumstances listed in the Medicare rules section of this letter.  
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 follow-up sleep studies. Our reviewer 
says that a polysomnography is not medically necessary. Our physician reviewer found you have a 20-year 
history of obstructive sleep apnea, treated with CPAP. Reportedly, the device you have is 20 years old and you 
are requesting a replacement device. Our reviewer found that the medical records provided do not provide 
justification of need for a new sleep study. There is no indication that the current CPAP settings are not 
meeting your needs. There is no documentation of a major change in your medical status or body weight.  Our 
physician reviewer also found that a new sleep study is not required to replace your current device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of follow-up sleep studies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve follow-up sleep studies (codes 95810 and 95811).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (G0299x38). 
 
You asked the Plan to pre-approve home health services. You say that the enrollee does not take his medication 
due to significant memory loss. The Plan denied your request. The Plan says the services are not medically 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any acute clinical status changes, medication or plan of care changes that 
would require the assessment/treatment by a skilled nurse in the home setting. The records do not show that 
thirty-eight (38) home health skilled nursing visits are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting, each 15 minutes (G0299x38).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five skilled nursing visits (G0299 x5), one additional 
physical therapy visit (G0151 x1), and two additional occupational therapy visits (G0152 x2). 
 
You asked the Plan to pre-approve five skilled nursing visits, one additional physical therapy visit, and two 
additional occupational therapy visits. The Plan denied your request. The Plan says the services are not 
medically 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 five skilled nursing visits, one 
additional physical therapy visit, and two additional occupational therapy visits. Our reviewer says that the 
services are not medically reasonable and necessary. Our physician reviewer found the clinical documentation 
does not specify any clinical status change, change in medications or plan of medical care thus the records do 
not show that five home health skilled nursing visits are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the patient's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five skilled nursing visits, one additional physical therapy visit, and two 
additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to 
pre-approve five skilled nursing visits (G0299 x5), one additional physical therapy visit (G0151 x1), and two 
additional occupational therapy visits (G0152 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power wheelchair. 
 
  You asked the Plan to pre-approve a new power wheelchair. You say that you cannot walk and do not 
understand why the scooter/wheelchair was denied. You also say that your current wheelchair is not working, 
and you use it for going places. The Plan denied your request. The Plan says the specific wheelchair you are 
requesting is not medically necessary for in home use. The Plan also says that you have a power operated 
vehicle that currently meets your needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 new power wheelchair. Our reviewer 
says that you do not meet the criteria for coverage. Our physician reviewer found the documentation available 
for review does not support that you require a power mobility device to accomplish mobility related self-care 
tasks in the home. Our reviewer also found that there is no indication that you are unable to use an alternative 
assistive device. 
 
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 new power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 20, 2023, billed with 
procedure code 20552 (2 units). 
 
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 20552 (2 units) is Injection(s); single or multiple trigger 
point(s), 1 or 2 muscle(s). 
 
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 that trigger finger injections are most 
commonly given to the flexor tendon, which is supported with CPT 20550.  
 
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 20, 2023, billed with procedure code 
20552 (2 units).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99233 
performed on June 17, 2023, and 99233 performed on June 18, 2023. 
 
You asked the Plan to pay for 99233 billed on June 17, 2023, and 99233 billed on June 18, 2023. You say that 
99233 billed on June 17, 2023, and 99233 billed on June 18, 2023, should be covered because they are 
supported in the documentation. The Plan denied your request. The Plan says 99233 billed on June 17, 2023, 
and 99233 billed on June 18, 2023, are denied because they are not supported in the 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 code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 99233 billed on June 17, 2023, and 99233 
billed on June 18, 2023. Our reviewer says that 99233 billed on June 17, 2023, and 99233 billed on June 18, 
2023, are not supported in the record. Our reviewer found documentation supports an appropriate exam, but not 
an appropriate history or medical decision making of high level for both dates of service June 17, 2023, and 
June 18, 2023, therefore code 99233 is not supported for either date.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 billed on June 17, 2023, and 99233 billed on June 18, 2023, have not 
been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services 
coded as 99233 performed on June 17, 2023, and 99233 performed on June 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection panel with bacterial add-on provided on 
March 7, 2022. 
 
You asked the Plan to pay for a fungal infection panel with bacterial add-on. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says a review of the medical literature and clinical 
practice guidelines do not support polymerase chain reaction (PCR) testing as a first line approach for 
evaluation of nail disorders and it is not widely accepted as standard of care. 
 
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 pay for a fungal infection panel with bacterial add-
on. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the longstanding standard of care for the evaluation of fungus in 
toenails is the performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are 
inexpensive, sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as 
compared to KOH and fungal culture. Therefore, the PCR testing of this enrollees left hallux toenail was 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 fungal infection panel with bacterial add-on have not been met. Therefore, we 
decided that the Plan does not have to pay for a fungal infection panel with bacterial add-on provided on March 
7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. 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 a special 
type of joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records document that you 
have 4 out of 5 upper extremity strength, are independent with eating, and are set-up assist for grooming and 
hygiene, thus indicating you have adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 13, 2023, to April 
5, 2023. 
 
You asked the Plan to pay for home health care. You say that you were not fully informed of the NOA 
requirements. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 13, 2023. The NOA was not received by the Plan until April 19, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from February 13, 2023, to April 5, 2023.