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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that the items in question are not an integral part of the base, thus a split decision should be 
possible. The Plan denied your request. The Plan says the requested electronic connection, expandable 
controller harness, and expandable controller exceeds the member's need and is not reasonable and necessary 
per Medicare criteria.  

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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2310), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and arthrocentesis rendered on June 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with incorrect diagnosis 
codes with left and right pointers for a bilateral procedure. 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 office visit and arthrocentesis rendered on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on August 25, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you are requesting reconsideration for the denied 
claim stating the patient chose the provider themselves and was aware that they were out of network. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 lab testing provided on August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom ramp and shower. 
 
You asked the Plan to pre-approve these services. You say that you have diabetic nerve damage and a broken 
foot. The Plan denied your request. The Plan says these services 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 custom ramp and shower.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and appliances 
(E0673 and E0667) provided on April 11, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. 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. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and appliances (E0673 and E0667) provided on April 11, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's care can continue to be provided in the 
current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support that LTACH services are currently medically 
appropriate. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two periodontal scalings and root planings of four or 
more teeth per quadrant (D4341 x2) and two periodontal scalings and root planings of one to three teeth per 
quadrant (D4342 x2). 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says this 
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 two 
periodontal scalings and root planings of four or more teeth per quadrant (D4341 x2) and two periodontal 
scalings and root planings of one to three teeth per quadrant (D4342 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 Plans 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 June 5, 2023. Therefore, 
we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services described by code 62322-59 billed for 
date of service October 12, 2023. 
 
You asked the Plan to pay for 62322-59. You say that 62322-59 should be paid as billed because it was 
administered primarily for postoperative analgesia at the request of the surgeon. The Plan denied your request. 
The Plan says 62322-59 is denied because it is not supported in the documentation and is included in payment 
for procedure code 00194 billed on the same date. 
 
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 62322 is injection(s), of diagnostic or therapeutic 
substance(s) (for example, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance. 
 
We find that CPT code 62322-59 is not supported in the medical record. Specifically, we confirmed that the 
records provided do not include documentation that an injection of diagnostic or therapeutic substances was 
performed. Without supporting documentation, this service cannot be verified. Without records to support that 
code 62322 was performed, it is also not possible to confirm if modifier -59 is supported. As such, 62322-59 is 
not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of 
62322-59 have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
described by code 62322-59 billed for date of service October 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from June 7, 2023, to July 
5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the provider was not a qualified provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. The records do not show that acupuncturist was under supervision of 
a qualified provider. The records show that the enrollee was being treated for neck pain that radiated down the 
right arm. There is insufficient documentation of treatment for chronic low back pain. Based on this 
information, we decided that the rules for coverage have not been met. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services provided from June 7, 2023, to July 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 21, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for right side abdominal pain. An appropriate history and 
physical were documented; However, the medical decision making was not of high complexity. As such, the 
billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740), core buildup 
(D2950 x2) and intraoral - periapical first radiographic image (D0220). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the crown has already been exhausted. A core buildup and 
intraoral - periapical first radiographic image are not covered services. 
 
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, certain limitations apply. The record 
shows your benefit for the crown was exhausted. A core buildup and intraoral - periapical first radiographic image are not covered services. Therefore, we decided that the Plan does not have to pre-approve crown - 
porcelain/ceramic (D2740), core buildup (D2950 x2) and intraoral - periapical first radiographic image 
(D0220).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 17, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found based on the 
provided documentation for this encounter in the emergency department (ED), the enrollee was relatively 
stable and only required straightforward monitoring and treatment. Although the history and examination are 
appropriate, the documentation does not sufficiently support a high level of medical decision-making to justify 
the code, 99285. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 17, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate services. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this procedure is not supported by research 
and is not covered. 
 
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 bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that bone marrow aspirate is considered experimental/investigational for 
use as bone graft material 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 the bone marrow aspirate services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bone marrow aspirate services (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on October 27, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 wound care supplies provided on October 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on May 22, 2023, billed with 
procedure codes 74177-26 and 71260-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 13, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on May 22, 2023, 
billed with procedure codes 74177-26 and 71260-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine and administration provided on 
September 29, 2023. 
 
You asked the Plan to pay for the shingles vaccine and administration. You say that the vaccine and 
administration fee should be paid. The Plan denied your request. The Plan says this service is not covered 
under your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration 
provided on September 29, 2023.  
 
  Benefits for the shingles vaccine and administration 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99284) provided on July 24, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99284). You say that procedure code 99284 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 an emergency department visit (99284). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the 
documentation from this encounter supports an appropriate history and examination; However, the 
documentation does not sufficiently support a moderate level of medical decision-making to justify the code, 
99284. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99284) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99284) provided on July 24, 
2023.