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

 
We decided that the Plan does not have to pre-approve a corpus arm gel pad left, a narrow corpus footplate, a 
corpus arm gel pad right, an adjust height panel bracket fixed, a shop collar, a thigh support bracket, and a 
custom option (K0108x7). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested accessories do not primarily serve a medical purpose. These 
cannot be covered as they are not reasonable and necessary per Medicare criteria. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a corpus arm gel pad left, a narrow corpus footplate, a 
corpus arm gel pad right, an adjust height panel bracket fixed, a shop collar, a thigh support bracket, and a 
custom option (K0108x7).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 24, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. 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 home visit provided 
on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on April 05, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that this is supported in the records. 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 a new patient office visit 
provided on April 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you need to bill the primary Plan first before submitting 
your claim to Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has if there is a 
primary Plan and the provider does not bill the primary Plan first, Medicare may not pay conditionally on the 
liability (including self-insurance), or no-fault. Providers must bill the primary Plan before billing Medicare. As 
the secondary insurer, the Plan cannot be held responsible for an office visit until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 9 (D2740).  
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was previously exhausted. Specifically, the Plan's contract states that 
3 porcelain/ceramic crowns are covered every year. The record shows that you previously received dental 
crowns for teeth number 29 and 30 on September 12, 2023 that were paid by the Plan. Additionally, the Plan 
recently approved a dental crown for tooth number 8. Therefore, you have exhausted the allowable benefit for 
the requested dental item in this case. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic crown for tooth number 9 (D2740).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits, and psychotherapy services provided on May 
26, 2023, to July 06, 2023. 
 
You asked the Plan to pay for office visits, and psychotherapy services. You say that this is supported in the 
records. 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 office visits, and 
psychotherapy services provided on May 26, 2023, to July 06, 2023.
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 E0955, E1007, E1012, E1028 x 2, E2311, 
E2313, E2359, E2377, E2607, E2611, K0040).  
 
You asked the Plan to pre-approve a group 3 power wheelchair and additional items and accessories. You say 
that the requested group 3 powered wheelchair with multiple power options (K0861) and additional items and 
accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2607, E2611, K0040) are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
group 3 power wheelchair with multiple power options (K0861) and additional items and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2607, E2611, K0040).  
 
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 group 3 power wheelchair and 
additional items and accessories. Our reviewer says that the enrollee does not meet criteria for a group 3 power 
wheelchair with multiple power options (K0861) and additional items and accessories (E0955, E1007, E1012, 
E1028, E2311, E2313, E2359, E2377, E2607, E2611, K0040).  Our physician reviewer found the member has 
a neurologic disorder with functional deficits. The documentation does not indicate that the member has any 
pressure injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate 
power tilt or recline.  Although the members condition may meet criteria for a power wheelchair, the criteria 
for this specifically requested power wheelchair are not met. 
 
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 power wheelchair 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 E0955, E1007, E1012, 
E1028 x 2, E2311, E2313, E2359, E2377, E2607, E2611, K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 8, 2023, billed 
with procedure code 81479. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 February 8, 2023, billed with procedure code 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3346) for 
tooth #27, 
 
You asked the Plan to pre-approve D3346. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service 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 
retreatment of previous root canal therapy (D3346) for tooth #27,
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing codes 87491, 87798, 87641, 87500, and 87640 
billed for date of service July 13, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing codes 87491, 87798, 87641, 87500, and 87640 billed for date of 
service July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) 
device (E0720) 
 
You asked the Plan to pre-approve a TENS device. You say that this device is needed for your bladder issues 
and you are trying to avoid surgery. The Plan denied your request. The Plan says the request for a TENS unit 
for overactive bladder does not meet the guidelines for approval. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transcutaneous electrical nerve stimulator (TENS) device (E0720)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this wheelchair and the requested 
components are necessary to meet the enrollee's mobility, medical and functional needs in their home. The Plan 
denied your request. The Plan says the notes do not show a medical need to control the power options through a 
joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided records document no impairment in the enrollee's upper extremity 
strength or function which would impair his ability to operate the wheelchair's power options with their own 
switches. Therefore, the reviewer found that the requested upgraded electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 11, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. 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 home visit provided 
on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service July 7, 2023.   
You asked the Plan to pay for procedure code 88341. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planning (D4341 x 2). We decided that the Plan does not have to pre-approve unspecified periodontal procedure (D4999).

You asked the Plan to pre-approve periodontal scaling and root planning (D4341 x 2) and unspecified periodontal procedure (D4999). You say that these procedures are required due to bone loss and generalized pocket sizes. The Plan says that this service is not a covered benefit under the enrollee's dental plan.

We decided that the Plan has to pre-approve periodontal scaling and root planning (D4341 x 2).

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. The Plan covers dental services when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant coverage rules to determine if the Plan was correct in denying the request to pre-approve the item/service at issue. Our reviewer says that the request is medically necessary. Our physician reviewer found that documentation from the provider dated September 12, 2023, indicates necessity of the procedures for the patient's long-term health and oral health due to severe gum bleeding with swelling and clinical attachment loss.

We looked at this physician's review, the file, and the Plan's coverage rules. Based on this information, we decided that the Plan's rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planning (D4341 x 2).

We also decided that the Plan does not have to pre-approve unspecified periodontal procedure (D4999).

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.

We looked at this physician's review, the file, and the Plan's coverage rules. Based on this information, we decided that the Plan's rules for coverage of the item/service at issue have not been met. Therefore, we decided that the Plan does not have to pre-approve unspecified periodontal procedure (D4999).

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 procedure codes 64447 and 64445 provided on July 27, 
2023. 
 
You asked the Plan to pay for procedure codes 64447 and 64445. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
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. 
 
We looked at the file and Medicare rules. Medicare guidelines state that modifiers -LT and -RT are to be used 
to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and 
ovaries. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals 
use the appropriate -LT or -RT modifier to identify which of the paired organs was operated upon. In this case, 
the file shows that the claim was not billed with an appropriate modifier. Therefore, we decided that the Plan 
does not have to pay for procedure codes 64447 and 64445 provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second surgical extraction of tooth #10, and bone 
replacement graft.  
 
You asked the Plan to pre-approve the dental services. You say that you would like reconsideration. The Plan 
denied your request. The Plan says the services remain denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the 
requested code for a bone graft (D4263) for a retained natural tooth is incorrect. The criteria for a second 
surgical extraction (D7210) #10 has not been met and remains denied because this is a submission error.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a second surgical extraction of tooth #10, and bone replacement graft.