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

 
We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy (OT) visits 
(97164 x 10). 
 
You asked the Plan to pre-approve the OT visits. You say that the services are medically necessary. 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 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 OT 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 the enrollee has a chronic condition and will need to perform 
maintenance program for an extended period of time. This phase does not require unique skills of a therapist. 
The treatment program established is effective and able to continue as a home program.  
 
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 OT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten (10) additional occupational therapy (OT) visits (97164 x 10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) 
provided on February 16, 2023.   
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service June 30, 2022. Specifically, the 
Plan's contract says that one intraoral-periapical first radiographic image is covered every three years. You 
previously received this service, less than three years prior, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay 
for the intraoral-periapical first radiographic image (D0220) provided on February 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) physical therapy home visits (G0151). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial and have 
submitted medical records for medical necessity review. 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 the enrollee 
has a past medical history of multiple comorbidities and recent evaluation for dog bite, and other mobility 
impairments. Clinical documentation shows that the enrollee has met all self-care/mobility goals. 
Documentation does not show that the enrollee is home-bound thus based on available documentation 4 
additional home health PT visits are not medically necessary. The records do not show that skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function 
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 four (4) physical therapy home visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee meets criteria 
for approval of the requested wheelchair and accessories. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for multiple power options included with a group 3 power wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
broken power wheelchair as she has hemiplegia from a stroke. She is not a high risk for skin breakdown as she 
has a chronic wheelchair use and no skin breakdown, she does not use intermittent catheterization and she does 
not have significant spasticity. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, E1007, E1012, 
E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone mass measurement billed with code 77080 for date
of service December 7, 2022.

You asked the Plan to pay for code 77080. You say that this service was medically necessary. The Plan denied
your request. The Plan says this service is not covered because you did not bill with a covered diagnosis.

The Plan must follow Medicare rules. Medicare rules say that bone mass measurements billed with code 77080
must be billed with one of the Group 1 ICD-10 codes in order to be covered. In this case, the only ICD-10 code
you billed on this claim is Z13.820. This ICD-10 code is not one of the covered codes listed in the Group 1
code list referenced above.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of code 77080 have not been met. Therefore, we decided that the Plan does not have to pay for the
bone mass measurement billed with code 77080 for date of service December 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CTA of the chest and a CTA of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CTA of the chest. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that a CTA of the 
chest is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CTA of the chest. Our reviewer says 
that a CTA of the chest is medically necessary. Our physician reviewer found that the enrollee was to have a 
CTA of the chest, abdomen, and pelvis in August 2022, however the exams were cancelled due to rising 
creatinine. The enrollee has had a negative nuclear medicine stress test. A CTA of the abdomen and pelvis has 
already been approved, and the CTA of the chest has been ordered. Both images should be performed in one 
sitting with a single dose of contrast to minimize the risk of having to repeat a CTA of the chest due to 
symptoms or findings on the CTA of the abdomen and pelvis. Therefore, the requested CTA of the chest 
should be approved and added to the already approved CTA of the abdomen and pelvis. 
 
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 CTA of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve a CTA of the chest and a CTA of the abdomen and pelvis.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 23, 2022 to October 22, 2022.

You asked the Plan to pay for SNF care. You say that you are appealing the denied payment for services with medical records. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at a SNF.

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 pay for 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 that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.

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 pay for skilled nursing facility (SNF) care provided from September 23, 2022 to October 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 2) and the bone replacement grafts for ridge preservation-per site 
(D7953 x 2) provided on January 12, 2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided has been exhausted. Specifically, your annual dental benefit 
maximum allowance is $2,500. You received additional dental services on January 9, 2023, January 24, 2023, 
February 9, 2023, and February 15, 2023 which were paid for by the Plan in the amount of $2,500. Therefore, 
you have exhausted the allowable benefit for the services provided in this case. Therefore, we decided that the 
Plan does not have to pay for the extractions, of an erupted tooth requiring removal of bone and/or sectioning 
of tooth (D7210 x 2) and the bone replacement grafts for ridge preservation-per site (D7953 x 2) provided on 
January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a customized seat cushion (E2609) and customized seat 
back (E2617).  
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the DME. Our physician reviewer 
found the enrollee is not at high risk for skin breakdown and does not have a diagnosis for which a customized 
seat back is 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a customized seat cushion (E2609) and customized seat back (E2617).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
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 for the certain indications. 
 
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 There is no imaging evidence of a fracture 
that is less than 6 weeks old and there is no documentation of adequate bracing. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 kyphoplasty. 
 
You asked the Plan to pre-approve L5 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 for certain indications. 
 
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 L5 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
lumbar bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L5 kyphoplasty.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for 99215 and 82950. We decided that the Plan does not have to pay for
93971.

You asked the Plan to pay for procedure codes 82950, 93971, and 99215 rendered on May 23, 2022.. You say
that this should be paid for. The Plan says that the records do not support the services billed.

The CPT code manual definition of the denied codes are:

CPT 82950:

Glucose; post glucose dose (includes glucose)

CPT 93971:

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited
study

CPT 99215:

Office or other outpatient visit for the evaluation and management of an established patient, which requires a
medically appropriate history and/or examination and high level of medical decision making. When using time
for code selection, 40-54 minutes of total time is spent on the date of the encounter

We decided that the Plan has to pay for 99215 and 82950.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request for CPT 99215 and 82950 Our reviewer says that the
medical records do not a level 5 evaluation and management code for CPT 99215, based on the higher level of
medical decision making. Additionally, blood glucose was tested, and therefore CPT 82950 is supported.

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 been met. Therefore, we decided that the Plan has to pay for
99215 and 82950.

We also decided that the Plan does not have to pay for 93971.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request for CPT 93971. Our reviewer says that this code
without a modifier is inappropriate. This was the professional component, and a modifier is required. The
medical records do not support this procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 93971 have not been met. Therefore, we decided that the Plan does not have to
pay for 93971.

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant (D4263 x2), guided tissue regeneration - resorbable barrier, per site (D4266 x2). 
 
You asked the Plan to pre-approve the dental services represented by codes D4263 and D4266. The Plan 
denied your request. The Plan says these services are not covered under your Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
bone replacement graft  retained natural tooth  first site in quadrant (D4263 x2), guided tissue regeneration - 
resorbable barrier, per site (D4266 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 63048) rendered July 13, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 63048 is "Laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or 
lumbar (List separately in addition to code for primary procedure)." 
 
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 there is no documentation of 
laminectomy with foraminotomy. There is documentation of ponte osteototomies. The laminotomy performed 
here is described for ponte osteotomy and not foramainal decompression. It should not be paid for and is 
included in the osteotomy code. 
 
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 surgical services (procedure code 63048) rendered July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system or equal (L5981).  
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the advanced foot exceeds the enrollee's need.  
 
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 item. Our physician reviewer found 
the documentation does not support that the enrollee is able to ambulate at a K3-functional level. There is no 
clear documentation to support the enrollee requires an upgraded foot. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a flex-walk system or equal (L5981).