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

 
We decided that the Plan has to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system (L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee's clinical notes support the need for 
the services requested and meets the LCD requirements. The Plan denied your request. The Plan says that 
Medicare guidance says that the advanced foot is not reasonable and necessary for the approved prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical record satisfies Medicare policy in demonstrating this enrollee likely has K3 
functional potential, and even taking into account the inconsistent documentation on this point, he also qualifies 
for the requested foot simply as a bilateral amputee. We note, on one hand, that these broad, inclusive K3-
criteria generally describe the average Medicare enrollee who lives independently at home and in the 
community, which this enrollee could very credibly do with the proper prostheses. On the other hand, the LCD 
is specifically lenient in prosthetic coverage criteria for bilateral amputees, in that it does not strictly hold them 
to K-level thresholds. The certified prosthetist/orthotist (CPO) note from July, taken alongside the primary care 
physician (PCP) note from September, more than satisfy Medicare requirements for documenting his general 
functional potential as well as his particular need for the new prosthetic foot in question, both of which qualify 
him for the requested foot per the LCD. There is no doubt that original Medicare would cover the requested 
prosthesis for this enrollee, a bilateral amputee with K3-level potential. Therefore, the requested foot (L5981, 
L5968) is hereby approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(L5968) and an all-lower extremity prosthesis, flex-walk system (L5981).  
 
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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided from February 10, 2023, 
to February 16, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated after a post-service, 
post-payment clinical validation audit was performed to help ensure that the diagnosis codes on the claim 
supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 377. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with right upper quadrant pain six months after a cholecystectomy. Pertinent 
laboratory findings included leukocytosis, anemia, hyperbilirubinemia, transaminitis, and a mildly elevated 
lipase. Additional evaluations confirmed mild gastritis with bleeding, fluid in the gallbladder fossa, a dilated 
common bile duct and a normal appearing pancreas. The results of a magnetic resonance imaging/magnetic 
resonance/magnetic resonance cholangiopancreatography (MRI/MRCP) are not identified.  Together, the 
findings point to a diagnosis of acalculous biliary disease, cholangitis or post-cholecystectomy syndrome, more 
than they do a diagnosis of isolated pancreatitis. As such, the billing of K85.90 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from February 10, 2023, to February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 5, 2023, to July 31, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 5, 
2023, to July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950). We decided that the 
Plan does not have to pre-approve an endosteal implant (D6010) and guided tissue regeneration (D4266).  
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan says that these services are either not covered benefits or your benefit for the requested item or 
service has already been exhausted. 
 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950).  
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950).  
 
We also decided that the Plan does not have to pre-approve an endosteal implant (D6010) and guided 
tissue regeneration (D4266). 
 
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 D6010 was exhausted on date of service June 26, 2023. Additionally, D4266 is not 
listed as a covered benefit in the EOC and is not covered under any circumstance. Therefore, we decided that 
the Plan does not have to pre-approve an endosteal implant (D6010) and guided tissue regeneration (D4266). 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has recurrent congestive 
heart failure (CHF). The CardioMEMS was approved by the Food and Drug Administration (FDA) in 2014. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMS Heart Failure (HF) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
19, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioventis OsteoAMP allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
spondylolisthesis of the lumbosacral region. She presents with back and bilateral leg pain with difficulty 
standing and prolonged walking. There is limited published, large-scale, long-term peer-reviewed literature that 
shows this requested Bioventis OsteoAMP allograft to be an effective and/or safe treatment for the noted 
pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Bioventis OsteoAMP 
allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Bioventis OsteoAMP allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SI) fusion. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in tremendous pain and their 
quality of life is decreasing. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for this procedure. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the magnetic resonance imaging (MRI) shows a normal joint. The enrollee has not completed three 
months of physical therapy. Therefore, the request does not meet the criteria and is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint (SI) fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity prosthesis, not otherwise specified, 
Revo socket (L5999). 
 
You asked the Plan to pre-approve the Revo socket. You say that the Revofit adjustable design is necessary for 
the enrollee to allow for better circulation and comfort while seated, driving and resting. The Plan denied your 
request. The Plan says the requested L5999 Revo socket is unbundled and does not meet Medicare criteria as 
reasonable and necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested Revo socket does not have FDA approval and does not 
meet Medicare criteria as safe and effective. The use of L5999 is incorrect coding (unbundling). L5999 must 
not be used for any features or functions of a socket. A standard socket was already approved. Based on this 
information, we decided that Medicare rules for coverage of the Revo socket have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the lower extremity prosthesis, not otherwise specified, 
Revo socket (L5999).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Synvisc syringe (J7325). 
 
You asked the Plan to pre-approve an injection. You say that the injection is necessary due to the enrollee's 
knee pain. The Plan denied your request. The Plan says that the documents submitted do not show if the 
enrollee meets the criteria for the requested medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 injection. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has bilateral osteoarthritis of his 
knees. He has had cortisone injections but is still having pain in the left knee. Synvisc is Food and Drug 
Administration (FDA) approved for therapy of knee osteoarthritis.  There is no literature to suggest that one 
Visco supplement is superior to any other. The request is 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 an injection have been met. Therefore, we decided that the Plan has to pre-
approve a Synvisc syringe (J7325).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (S9122). 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee is no longer receiving skilled 
nursing or therapy services which is required to meet the eligibility for aide services. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. As 
such, home health services, including associated HHA services, are not medically necessary or reasonable. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health services (S9122).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 15, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you are asking for this claim to be 
reconsidered for payment based on medical necessity. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two 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 81456 billed for date of service April 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periapical x-rays (D0220, D0230), the oral/facial 
photographic image (D0350x2), the bitewing x-rays (D0274), and the dental surface scan (D0801) provided on 
July 28, 2023. 
 
You asked the Plan to pay more for the periapical x-rays (D0220, D0230), the oral/facial photographic image 
(D0350x2), the bitewing x-rays (D0274), and the dental surface scan (D0801). You say that you specifically 
chose the PPO plan in order to use the out-of-network benefits. The Plan denied your request. The Plan says the 
claim processed correctly according your out-of-network benefits. The Plan says D0350 and D0801 are not 
covered benefits. The Plan says the benefit for D0274 has 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the periapical x-rays (D0220, D0230). This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Though the Plan offers a dental benefit in excess of Medicare coverage, the 
oral/facial photographic image (D0350x2) and the dental surface scan (D0801) are not among those covered 
under this benefit. The record shows your benefit for the bitewing x-rays (D0274) was exhausted on date of 
service January 27, 2023. Therefore, we decided that the Plan does not have to pay more for the periapical x-
rays (D0220, D0230), the oral/facial photographic image (D0350x2), the bitewing x-rays (D0274), and the 
dental surface scan (D0801) provided on July 28, 2023. 
  
Your complaint that the Plan is unethical, misleading and engage in false advertising 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: 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 you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 documentation does not support that this enrollee requires skilled nursing services 
with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively 
provide care only in a SNF. The enrollee does not have complex wound care, intravenous (IV) antibiotics, new 
enteral feedings or other skilled nursing need that require a SNF admission. The enrollee's high functional level 
does not require the skills of a professional therapist only in a SNF. He is near baseline. A home exercise 
program was reviewed with the enrollee. The enrollee does not require skilled nursing or skilled therapy on a 
daily basis. As a practical matter this enrollee's needs do not require the necessary services on an inpatient basis 
in a SNF. 
 
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.