Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that you have developed an additional 
stress factor and are having a hard time walking due to not being able to fully extend your knee. The Plan 
denied your request. The Plan says 6 additional physical therapy visits are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have improved with therapy to the point of 
having full knee range of motion and good quadriceps control. The records do not support that the complexity 
of your conditions require a skilled therapist for further improvement in your symptoms or functional status. 
Therefore, a home exercise program is appropriate. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that the provider was an in-
network provider so the dental services should be covered. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the Plan paid for the intraoral radiographic images (D0220) on February 23, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of February 23, 2023. Therefore, 
we decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 3, 2023, through January 
16, 2023, by an OON provider.  
 
You asked the Plan to pay for SNF care. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for SNF care provided from January 3, 2023, through 
January 16, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary when specific 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided lumbar magnetic resonance 
imaging (MRI) corroborated that the compression fracture at L3 was acute with loss of height by 25%. He does 
have noted worsening pain. However, there is no indication of the progression of vertebral body height loss, 
that the body height loss of greater than 25%, or kyphotic deformity. Moreover, the MRI demonstrated 
significant other plausible causes of lumbar spine pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 25, 2023, billed 
with codes 74230, 74240, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. This service is a barium swallow study and 
includes the administration of a substance to the patient. Therefore, we decided that the Plan does not have to 
pay for radiological services provided on January 25, 2023, billed with codes 74230, 74240, 72040, 70100, and 
70310.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the polycarbonate lenses provided on May 5, 
2022. 
 
You asked the Plan to pay for the frames and the polycarbonate lenses. You say that you are being billed twice 
for the same service. You say you want the claim to be approved for payment because you did obtain the 
glasses you wear daily. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $115 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $115 for the vision services on May 5, 
2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the frames and the polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have 
to pay for the frames and the polycarbonate lenses provided on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthese allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the 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 the allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Synthese allograft is experimental in spine surgery. Iliac crest autograft is the gold standard. It 
is not needed in this case.  

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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synthese allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
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 a Group 3 PWC is covered when specific 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that the enrollee has 
multiple medical problems with functional deficits; however, there is no documentation that there are any 
pressure injuries, spasticity that necessities power tilt and recline, or that he requires intermittent catheterization 
of the bladder. The criteria for coverage for the Group 3 PWC with multiple power options are not met and the 
services are therefore not reasonable or medically 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 Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) and 
the gingival irrigation (D4921) for tooth #14, #15, #18, and #20 provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you called the Plan you were told the 
provider was an in-network provider. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the localized delivery of antimicrobial agents and the gingival irrigation are 
not covered by the Plan. 
 
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, 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 the 
localized delivery of antimicrobial agents (D4381) and the gingival irrigation (D4921) for tooth #14, #15, #18, 
and #20 provided on March 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity.  
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the x-ray and ultrasound results don't show concerning findings that suggest 
additional imaging is needed.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the enrollee has a non-healing wound on the 
right lower extremity. The x-rays and lower extremity ultrasound on June 7, 2023, were negative. The enrollee 
was seen on June 7, 2023, and the MRI was ordered however the enrollee was evaluated in the wound 
care center on June 8, 2023, and described the wound as improved and not in need of surgical 
intervention. These evaluations were over 1 month ago so the medical necessity of the requested MRI of the 
right leg has not been established in the records provided. If there has been a substantial change in the interim a 
repeat request with additional information attached should be submitted for supplemental review. 

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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant (D6010 x2), prefabricated 
abutment (D6056 x2), abutment supported retainer (D6068), and pontic (D6245 x5). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. 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 item or service is exhausted. Therefore, we decided that the Plan does not 
have to pre-approve surgical placement of implant (D6010 x2), prefabricated abutment (D6056 x2), abutment 
supported retainer (D6068), and pontic (D6245 x5).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that both PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when specific 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the current back pain cannot be determined 
to be primarily due to the L3 compression fracture. Therefore, the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the purchase of the furniture portion of a lift  
chair is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Although a seat lift 
chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items 
that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 test billed for date of service September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support medical necessity. The Plan 
denied your request. The Plan says that the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and Medicare rules. A review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for the Guardant360 test billed for date of 
service September 8, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on December 27, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare doesn't cover routine eye exams (eye refractions) for 
eyeglasses/contacts. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for the eye refraction provided on December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93923 for date of service December 17, 
2022. 
 
You asked the Plan to pay for procedure code 93923. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 93923 is complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements 
with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or 
more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with 
provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with 
reactive hyperemia). 
 
We find that CPT code 93923 is not supported in the medical record. Specifically, the medical records indicate 
that limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, was performed. 
There is a more appropriate code to be billed for the services rendered. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93923 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93923 for date of service December 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival irrigation (D4921). 
 
You asked the Plan to pre-approve D4921. You say that you need all this dental work. The Plan denied your 
request. The Plan says D4921 is not a covered benefit. 
 
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 pre-approve a 
gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for the billed services. You say that no units were paid for the date of service. The 
Plan denied your request. The Plan says the requested documentation was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are no medical records to show that the additional 
units were provided, correctly coded, and medically necessary. The file shows that the Plan made several 
requests to obtain additional information with no success. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77002 billed for date of service November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (A0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (A0265).