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

 
We decided that the Plan does not have to pre-approve the orthotic device to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the orthotic device. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says while the enrollee can get their care from an out-of-network provider, 
the provider must be eligible to participate in Medicare. Except for emergency care, the plan cannot pay a 
provider who in not eligible to participate in Medicare. If the enrollee goes to a provider who is not eligible to 
participate in Medicare, the enrollee will be responsible for the full cost of the service they receive. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the orthotic device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment coded as A7007-NU 2 units, 
A7012-NU 2 units, A7526 14 units and A7002-NU 4 units provided July 17, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you request review of your appeal 
and reconsideration of the denial for claims A7007, A7012, A7526 and A7002. The Plan denied your request. 
The Plan says the number dispensed does not match the number requested on the physician's order.  
 
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 A7007 is large volume nebulizer, disposable, unfilled, 
used with aerosol compressor; A7526 is tracheostomy tube collar/holder; A7012 is water collection device, 
used with large volume nebulizer and A7002 is tubing, used with suction pump, each. 
 
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 durable medical equipment. Our reviewer says that the 
billed services are not supported in the provided records. Our reviewer found for A7007-NU 2 units; the 
documentation does not support 2 units billed. The physician order does not include documentation of number 
of large volume nebulizer, disposable to dispense. For A7526 14 units; the documentation does not support 14 
units billed, as the physician order does not specify number of tracheostomy tube collar/holders to dispense. 
For A7012-NU 2 units; the documentation does not support 2 units billed, as physician order does not specify 
number of water collection device to dispense.  For A7002-NU 4 units; the documentation does not support 4 
units billed, as physician order does not specify number of suction pump tubing to dispense. Therefore, the 
billed services cannot be verified. 
 
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 durable medical equipment have not been met. Therefore, we decided that 
the Plan does not have to pay for the durable medical equipment coded as A7007-NU 2 units, A7012-NU 2 
units, A7526 14 units and A7002-NU 4 units provided July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) provided on April 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you have good and sufficient cause to request a 
dismissal to be vacated. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2331) provided on 
April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump, 
per cassette or bag (list drugs separately) (A4223) and supplies for maintenance of noninsulin drug infusion 
catheter, per week (list drugs separately) (A4221) provided April 13, 2023, to April 19, 2023. 
 
You asked the Plan to pay for the infusion supplies. You say that the codes billed are valid and reimbursable 
and the claim should not have been denied. The Plan denied your request. The Plan says this service is not 
covered by Medicare. 
 
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. There is no documentation that the supplies are used with a covered 
external infusion pump. Infusion pumps and associated supplies and drugs are not covered when the drug can 
be safely administered without an infusion pump.  Based on this information, we decided that Medicare rules 
for coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for the infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) 
(A4223) and supplies for maintenance of noninsulin drug infusion catheter, per week (list drugs separately) 
(A4221) provided April 13, 2023, to April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 2, 2023, billed with 
procedure code 11046-76 (x2). 
 
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 documentation does not support the billed code. 
 
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 physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that there is no evidence that a second, 
separate procedure was performed.  As such, the 76 modifier does not apply. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 2, 2023, billed with procedure code 
11046-76 (x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L2 kyphoplasty (22515). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria are not met as there is no documentation of an acute (less than 6 
weeks) or subacute (6-12 weeks) VCF at L2 on MRI. The Plan states greater than three vertebral fractures per 
procedure is considered a relative contraindication. 
 
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 service. 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 magnetic resonance imaging (MRI) evidence that the L2 fracture is less than 6-12 
weeks old. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the L2 kyphoplasty (22515).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you need the remaining visits to get the 
wound healed and get back to normal. 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 that the 
documentation does not support that you require additional skilled nursing services. You do not require 
additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the 
enrollee's condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven (7) skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the range of motion assist device to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the range of motion assist device. You say that you are requesting 
reconsideration of the denied item. The Plan denied your request. The Plan says the item was not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve the item. Therefore, we decided that the Plan does not have to pre-approve the range of motion 
assist device to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on August 31, 2023.

You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall within your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for maxillary partial dentures (D5225) provided on August 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 units of home health physical therapy 
visits (G0151). 
 
You asked the Plan to pre-approve home health services. You say that these services are necessary and 
appropriate. The Plan denied your request. The Plan says the additional services requested 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 Plan has 
already approved 8 physical therapy visits. The enrollee is walking at a community level. The additional visits 
already approved by the Plan are sufficient to return the enrollee to maximal function. The additional physical 
therapy visits requested are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 16 units of home health physical therapy visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new bathtub and shower. 
 
You asked the Plan to pre-approve the new bathtub and shower. You say that a shower upgrade is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
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 new bathtub and shower.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87491 billed for date of service 
August 2, 2023. 
 
You asked the Plan to pay for procedure codes 87640 and 87491. 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 87640 is 
bundled into payment for code 87641. Additionally, the medical records do not support the billing of procedure 
code 87491. 
 
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 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
Additionally, the CPT Code Manual definition of code 87491 is Infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491 is not 
supported in the medical record as the results for this test were not provided for review. 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 codes 87640 and 87491 billed for date of service August 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), 
amplified probe technique (87635) provided on July 17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you only process specimens that are being 
sent to your facility by patients primary physicians that are participating in the insurance accepted. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 
[COVID-19]), amplified probe technique (87635) provided on July 17, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486, 70350, 70355). 
 
You asked the Plan to pre-approve the oral appliance. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the requested dental provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve an oral appliance (E0486, 70350, 
70355).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve a crown on tooth #20 and 21 (D2750). We also decided that the Plan does not have to pre-approve core build up on tooth #20 and 21 (D2950).

You asked the Plan to pre-approve crowns and core build up. You say that you went to your dentist to repair the crowns that are causing you pain and anxiety. The Plan denied your request. The Plan says that the coverage criteria for the requested services have not been met.

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 crowns and core build up when the services are medically necessary and reasonable.

We decided that the Plan has to pre-approve a crown on tooth #20 and 21 (D2750).

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 crowns. Our reviewer says that the requested crowns are medically necessary. Our physician reviewer found that tooth #20 and #21 have existing porcelain crowns with parts of the crown fractured off exposing each tooth. When a tooth that has an existing restoration like a crown that has been fractured, it is medically necessary to replace the crown as it will be difficult to eat. The exposed tooth structure of teeth that have been prepared for a crown tend to be very sensitive. Based on the x-rays submitted, the requested crowns on tooth #20 and 21 are medically reasonable and necessary.

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 a crown have been met. Therefore, we decided that the Plan has to pre-approve a crown on tooth #20 and 21 (D2750).

We also decided that the Plan does not have to pre-approve core build up on tooth #20 and 21 (D2950).

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 core build up. Our reviewer says that the requested core build up is not medically necessary. Our physician reviewer found that there is enough tooth structure to retain a crown. A different procedure code may be more appropriate if there is a small area of decay.

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 core build up have not been met. Therefore, we decided that the Plan does not have to pre-approve core build up on tooth #20 and 21 (D2950).

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 31500 and 92950 rendered on October 13, 
2022. 
 
You asked the Plan to pay for the serivces. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 31500: 
 
Intubation, endotracheal, emergency procedure  
CPT 92950: 
 
Cardiopulmonary resuscitation (eg, in cardiac arrest) 
 
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 serivces. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 31500, the 
medical records describes that the enrollee presented to the emergency room on October 13, 2022, and was 
admitted for critical care. On October 14, 2022, a "code blue" was documented, the patient was intubated. in 
this case, the procedure report does not include documentation of the billed codes for the billed date of service - 
October 13, 2022. 
 
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 serivces have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 31500 and 92950 rendered on October 13, 2022.