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

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0953, E1007, 
E1012, E2300, E2311, E2313, E2361, E2377, E2620, E2624, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee is depending on their medical insurance to provide 
all the medical services and supplies they need to maintain their quality of life. The Plan denied your request. 
The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for which a K0861 
group 3 power wheelchair is medically needed. The Plan also says the expandable controller, harness and 
electronics are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee has paraplegia, and is able to transfer 
and toilet themself independently. Our reviewer also found that the enrollee does not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. 
 
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 Group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E0953, E1007, E1012, E2300, E2311, E2313, E2361, E2377, E2620, 
E2624, and K0040).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 18, 2023, and billed with codes 87481, 87150, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on April 18, 2023, and billed with codes 87481, 87150, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 24, 2022, billed with 
procedure code 44799. 
 
You asked the Plan to pay for the practitioner services provided. You say that 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 procedure code 44799 is unlisted procedure, small 
intestine. 
 
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 the unspecified code that was 
submitted is incorrect as there is a more specified CPT code to submit for this procedure, as well as the "other 
esophagitis without bleeding" diagnosis code is incorrect as there a more specified diagnosis code for the post 
operative diagnosis. 
 
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 June 24, 2022, billed with procedure code 
44799.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331 and D2332) for tooth #7, 
#8, and #27 provided on April 5, 2023, and June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should not be paying this much for dental 
services and the Plan is not covering your dental work. The Plan denied your request. The Plan says your 
annual dental maximum benefit for the year 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 the Plan paid $1,000 for dental services on January 5, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 5, 2023. Therefore, we decided that 
the Plan does not have to pay for a resin-based composite (D2331 and D2332) for tooth #7, #8, and #27 
provided on April 5, 2023, and June 8, 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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to an IRF.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital services (procedure code 99223) rendered on 
April 8, 2023. 
 
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 records do not support the services billed. 
 
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 99223 is "Initial 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, 75 minutes must be met or exceeded." 
 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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 75 minutes 
were spent. 
 
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 initial hospital services (procedure code 99223) rendered on April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, angiogram, injection, and ophthalmic scan 
provided on March 01, 2023. 
 
You asked the Plan to pay for the office visit, angiogram, injection, and ophthalmic scan. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit, 
angiogram, injection, and ophthalmic scan provided on March 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this is medically necessary. The 
Plan denied your request. The Plan says implantable loop recorders are not needed for routine assessment of 
patients with atrial fibrillation. 
 
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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable cardiac monitor. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288). 
 
You asked the Plan to pre-approve a sling operation for stress incontinence. You say that this is medically 
necessary. The Plan denied your request. The Plan says this request is not medically necessary because the 
records do not show that the enrollee has failed conservative management of the stress incontinence. 
 
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 sling operation for stress 
incontinence. 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 in this case do not document trial and 
failure of conservative measures or an explanation as to why conservative measures are not indicated. 
 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 sling operation for stress incontinence have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 14, 2023, billed with 
procedure code 93306. 
 
You asked the Plan to pay for the practitioner services provided. You say that 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 procedure code 93306 is echocardiography, transthoracic, 
real-time with image documentation (2D), includes M-mode recording, when performed, complete, with 
spectral Doppler echocardiography, and with color flow Doppler echocardiography. 
 
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 a more specific code should be 
reported to support procedure without spectral or color Doppler echocardiography. 
 
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 March 14, 2023, billed with procedure code 
93306.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 01, 2023, to May 
15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was residing in a nursing 
facility when services were provided. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 01, 2023, to May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on October 04, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you do not 
feel liable for the cost share applied because the facilitys negligence. 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 $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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. The total you owe is $257.49, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on October 04, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 10, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that services received 
were medically necessary. 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 $65 
copayment for emergency care. 
 
You have been asked to pay a $65 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 copayment for an emergency room 
(ER) visit provided on June 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chiropractic services provided on 
December 12, 2022. 
 
You asked the Plan to reduce the coinsurance for chiropractic services. You say that you believe you should be 
paid more. 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 50% 
coinsurance for Chiropractic services. 
 
You have been asked to pay 50% coinsurance for chiropractic services. This item/service falls within the 
Chiropractic 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. The total you owe is $18.78 ($37.55 allowed amount x 50% = $18.78). Therefore, we 
decided that the Plan does not have to reduce the coinsurance for chiropractic services provided on December 
12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) and myocardial 
strain imaging.  
 
You asked the Plan to pre-approve TTE and myocardial strain imaging. You say that TTE and myocardial 
strain imaging is medically necessary. The Plan denied your request. The Plan says per the provided 
documentation the patient is with no new symptoms, no change in exam reported. The echocardiogram 
showing mild aortic stenosis and mild mitral stenosis. There are no indication of need for an annual 
echocardiogram with mild valvular disease. A study similar to the one requested has already been performed. 
We need results of the prior study that show the need for repeat imaging. 
 
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 TTE and myocardial strain imaging. Our reviewer says that the requested TTE and myocardial strain imaging is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee is an asymptomatic male with 
mild mitral and aortic stenosis, hypertension (HTN), Left ventricular hypertrophy (LVH), in normal sinus 
rhythm was recommended to have an echocardiogram for evaluation of progression of valvular heart disease. 
The enrollee has had an unremarkable echo cardiogram about a year ago. A follow-up echocardiogram for 
asymptomatic mild valvular heart disease is every 3-5 years and the patient does not benefit from it. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE and myocardial strain imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve TTE and myocardial strain imaging.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the requested service does not meet the 
requirements for approval. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/ investigational therapy. It is the subject of ongoing 
clinical trials. Therefore, the request 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.