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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2601, E2611, K0861, E1028). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 power mobility devices are 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found you 
have a neurologic disorder with functional deficits. The documentation does not indicate that you have any 
pressure injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate 
power tilt or recline. Although your condition may meet criteria for a power wheelchair, the criteria for this 
specifically requested power wheelchair with multiple power options including power tilt and recline 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 accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2359, E2377, E2601, E2611, K0861, E1028).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will need inpatient 
admission after surgery. The Plan denied your request. The Plan says that inpatient admission is not medically 
necessary. Observation level hospital stay will meet the enrollee's medical needs. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the provided records in this case document that at the time of inpatient admission the 
admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 61590, 64742, 35701, 61605, and 38724 
provided on October 12, 2021. 
 
You asked the Plan to pay for procedure codes 61590, 64742, 35701, 61605, and 38724. You say that the 
medical records support the billing of codes 61590, 64742, 35701, 61605, and 38724.  The Plan denied your 
request. The Plan says the medical records do not support the billing of codes 61590, 64742, 35701, 61605, and 
38724.  
 
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 61590 is Infratemporal pre-auricular approach to middle 
cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without 
disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of 
the facial nerve and/or petrous carotid artery. The definition of code 64742 is Transection or avulsion of; facial 
nerve, differential or complete. The definition of code 35701 is Exploration not followed by surgical repair, 
artery; neck (eg, carotid, subclavian). The definition of code 61605 is Resection or excision of neoplastic, 
vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural. The 
definition of code 38724 is Cervical lymphadenectomy (modified radical neck dissection). 
 
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 procedure codes 61590, 64742, 35701, 61605, and 38724. 
Our reviewer says that the medical records do not support the billing of codes 61590, 64742, 35701, 61605, 
and 38724.  Our reviewer found the provided records in this case do not document details of the surgical 
procedures which fully satisfy the requirements for codes 61590, 64742, 35701, and 61605. Additionally, the 
provided records in this case do not support that CPT code 38724 was distinct from CPT code 42426.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 61590, 64742, 35701, 61605, and 38724 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 61590, 64742, 35701, 61605, and 
38724 provided on October 12, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005. We decided that the Plan does not have to pay 
for procedure codes 87801, 87798, 87486, 87581, 87634, 87498, 87502, and 87503.  
 
You asked the Plan to pay for procedure codes U0005, 87801, 87798, 87486, 87581, 87634, 87498, 87502, and 
87503 provided on February 27, 2023. You say that you would like the Plan to reconsider their denial of 
payment. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for procedure code U0005.  
 
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 U0005 is infectious agent detection by nucleic acid; 
severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [Covid-19]), amplified 
probe technique, making use of high throughput technologies, completed within 2 calendar days from date of 
specimen collection (list separately in addition to either code U0003 or U0004). 
 
We find that CPT code U0005 is supported. In this case, we have confirmed that code U0005 is an add-on code 
that has been billed with an appropriate primary procedure code. The file shows that primary code U0003 will 
be paid by the Plan. 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 procedure code U0005.  
 
We also decided that the Plan does not have to pay for procedure codes 87801, 87798, 87486, 87581, 
87634, 87498, 87502, and 87503. 
 
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 find that CPT codes 87801, 87798, 87486, 87581, 87634, 87498, 87502, and 87503 are not supported in the 
medical record. Specifically, a single comprehensive code should be reported in this case. 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 procedure codes 87801, 87798, 87486, 87581, 87634, 87498, 
87502, and 87503. 
 
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 mandibular partial denture - cast metal framework 
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you were told by a 
representative that your dental has an annual maximum of $3000.00 at the time you signed up. The Plan denied 
your request. The Plan says this service is not a covered expense under your plan. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D010) for teeth 
numbers 19 and 31 and a bone graft at time of implant placement (D6104) for teeth number 31 and 31. 
 
You asked the Plan to pre-approve the surgical placement of implant body (D010) for teeth numbers 19 and 31 
and a bone graft at time of implant placement (D6104) for teeth number 31 and 31. You say that your dentist 
said the tooth was not strong enough to hold a crown without the implant. The Plan denied your request. The 
Plan says this 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 the 
surgical placement of implant body (D010) for teeth numbers 19 and 31 and a bone graft at time of implant 
placement (D6104) for teeth number 31 and 31.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vectibix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on May 23, 2023. 
 
You asked the Plan to pay for the consultation. You say that the dentist provided a second opinion and then 
removed a tooth on June 8, 2023. The Plan denied your request. The Plan says this service is not covered under 
your plan. 
 
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 pay for a consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 31, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth (D4212). 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that the medical records support 
the medical necessity. The Plan denied your request. The Plan says the code D4212 is not listed as covered. 
 
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 the 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment  includes modification and 
placement (D6056), surgical placement of implant body: endosteal implant ( D6010), and implant supported 
crown - porcelain fused to high noble alloys (D6066). 
 
You asked the Plan to pre-approve the prefabricated abutment, surgical placement of implant body and the 
implant supported crown - porcelain. You say your dentist said that without the implant your gums are and will 
be bleeding in the future. You also say that it is painful when you eat and talk. The Plan denied your request. 
The Plan says these services must be part of your dental benefit for us to pay for it. The Plan also says dental 
implants and all associated services are excluded from coverage. 
 
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 
prefabricated abutment  includes modification and placement (D6056), surgical placement of implant body: 
endosteal implant ( D6010), and implant supported crown - porcelain fused to high noble alloys (D6066).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277). 
 
You asked the Plan to pre-approve HBO therapy. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found hyperbaric oxygen is not standard 
therapy for hearing loss and is not 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 SI joint fusion. 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 SI joint instability, fracture. or lesion. Si joint fusion for degenerative back pain is 
experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27279).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation (A0425, 
A0428). 
 
You asked the Plan to pre-approve non-emergent ambulance transportation. 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. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance 
transportation. Our reviewer says that the services are not medically necessary Our physician reviewer found 
documentation does not detail why other means of transport (such as stretcher van, wheelchair van, taxi, private 
car, or other type of vehicle) were contraindicated for this enrollee. Documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance can provide for safe transport. The documentation does not support that ambulance transport is 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergent ambulance transportation (A0425, A0428).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia for the first 15 minutes 
(D9222) and deep sedation/general anesthesia for each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia for the first 15 minutes (D9222) and deep 
sedation/general anesthesia for each subsequent 15 minute increment (D9223). You say that you have high 
anxiety, and he is getting a lot of his teeth extracted. The Plan denied your request. The Plan says the requested 
sedation 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 deep 
sedation/general anesthesia for the first 15 minutes (D9222) and deep sedation/general anesthesia for each 
subsequent 15 minute increment (D9223).