Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthroscopy, of the shoulder, surgical; with rotator 
cuff repair (29827).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for a partial torn rotator cuff. He presented with right shoulder pain 
that began in 2016. The pain is sharp in the anterior, posterior, superior aspects, and into the right biceps. 
Symptoms are aggravated by movement and relieved by nothing. The pain is rated at 5/10.   
 
 
 
The exam of the right shoulder reveals tenderness in the biceps tendon. The active abduction is 90 with pain, 
passive abduction is 100, extension is 60, external rotation is 30, forward flexion is 90 with pain, and internal 
rotation is normal. Strength is 4/5 in internal rotation and 3/5 in supraspinatus. Drop arm testing and Speeds 
tests are positive. The x-rays of the right shoulder from August 8, 2023 have impressions of minimal right 
acromioclavicular joint osteoarthritis and minimal rotator cuff enthesopathy.  
 
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested arthroscopic rotator cuff repair is 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an arthroscopy, of the shoulder, surgical; with rotator cuff repair (29827).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87150, 87481, 87641, 87653, 87798, and 
87801) provided on June 8, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. 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 find that CPT codes 87150, 87481, 87641, 87653, 87798, and 87801 are not supported in the medical 
record. Specifically, a panel was performed and there is a more appropriate singular code for the services. 
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 pay for the panel testing (87150, 87481, 87641, 87653, 
87798, and 87801) provided on June 8, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 17, 2023, 
through February 19, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was evaluated and treated for acute hypoxic respiratory failure/Covid positive/Covid 
pneumonia. He was treated with supplemental oxygen, intravenous (IV) fluids, and IV antibiotics which 
include Ceftriaxone/Azithromycin, IV steroids and IV Remdesivir. The enrollee was admitted. His condition 
stabilized and improved and he was discharged home when considered medically stable on February 19, 2023. 
The review has determined that the record showed that at the time of the inpatient admission it was reasonable 
for the admitting physician to expect that the enrollees necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 17, 2023, through February 19, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 15, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service June 19, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99284 is bundled into 
payment for code 99285. 
 
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, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy services on May 30, 2023. 
 
You asked the Plan to waive the deductible for physical therapy services. You say that you are requesting 
reconsideration stating that when verifying the members benefits, it stated that the member had a $30 copay. 
You believe that the claim processed incorrectly as you are participating with the plan. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time physical therapy services was received on May 30, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy services on May 
30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided 
from July 6, 2023, to July 16, 2023. 
 
You asked the Plan to waive the copayments for the ambulance transportations. You say that you would like 
for the services to be fully covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each covered, one-way ambulance trip by ground or water.  
 
 
 You have been asked to pay a $200 copayment for the ambulance transportations provided on July 6, 2023, and 
July 11, 2023. You have been asked to pay $110, which is less than the standard copayment for the ambulance 
transportation provided on July 16, 2023. These items/services fall within the ambulance services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the ambulance transportations provided from 
July 6, 2023, to July 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyeglasses purchased on June 4, 2023. 
 You asked the Plan to reimburse for eyeglasses. You say that you do purchase your eyeglasses through an on-
line provider. You also say you have never had any issues with glasses from this company and are very 
pleased. The Plan denied your request. The Plan says you must use contracted providers. 
 
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 when you use an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use contracted providers for vision 
examinations and eyewear. Based on this information, we decided that the Plan's rules for coverage of 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse for eyeglasses 
purchased on June 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 8, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you are asking for reconsideration per the 
submitted Medicaid denied documentation and reprocess the claim towards payment. The Plan denied your 
request. The Plan says the claim was received past 1 year from last date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until April 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the abdomen. 
 
You asked the Plan to pre-approve CT scan of the abdomen. You say that the enrollee has severe lower 
abdominal pain and needs this to find out why. The Plan denied your request. The Plan says this 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 CT scan of the abdomen. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found absent review of the MRI of the 
abdomen done dated 2/15/22 the medical necessity of the requested CT of the abdomen has not been 
established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT scan of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard-hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested item is not covered under the 
supplemental dental policy. 
 
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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard-
hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you have been going to the gym facility 3 
times a week and are requesting to continue this process because of the positive results.  The Plan denied your 
request. The Plan says the record shows that as of October 10, 2023 you have completed 16 trips and an 
additional 36 one-way trips would exceed your benefit limit.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 36 
additional trips for transportation to the gym. Based on this information, we decided that you will have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 36 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty (D7320). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford this procedure and it is 
required so you can property wear your denture. The Plan denied your request. The Plan says this service is not 
a covered benefit under your dental 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 pre-approve an 
alveoloplasty (D7320).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics-porcelain fused to high noble metal (D6240 x 3) 
and retainer crowns-porcelain fused to high noble metal (D6750 x 2).  
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit.  
  
 
 
 
Therefore, we decided that the Plan does not have to pre-approve pontics-porcelain fused to high noble metal 
(D6240 x 3) and retainer crowns-porcelain fused to high noble metal (D6750 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you feel the requested item is medically 
necessary due to the enrollee's recurrent falls. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction device (E0849). 
 
You asked the Plan to pay for a cervical traction device. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have a covered diagnosis for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that cervical traction devices described by code 
E0849 or E0855 are covered only when criteria 1 and 2 above and either criterion A, B or C below has been 
met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment 
for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a 
chin halter is unable to be utilized; or, 
C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a cervical traction devices have not been met. Therefore, we decided that the Plan does not have to 
pay for a cervical traction device (E0849).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of the implant body (D6010), the 
surgical access to an implant body (D6011), and the sedation (D9222 and D9223) for tooth #10 provided on 
February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that it is an uncommon medical problem which had 
to be taken care of by dental professionals. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because you do not have enhanced dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of the 
implant body (D6010), the surgical access to an implant body (D6011), and the sedation (D9222 and D9223) 
for tooth #10 provided on February 23, 2023.