Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing to aid 
in hemostasis or clot stabilization, per site (D7922), and gingival irrigation - per quadrant (D4921). 
 
You asked the Plan to pre-approve the dental services represented by codes D7210, D4341, D7922 and D4921. 
The Plan denied your request. The Plan says D7922 and D4921 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services represented by 
D7922 and D4921 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per 
site (D7922), and gingival irrigation - per quadrant (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office evaluation and management (EM) provided on 
November 16, 2022, billed with code 99213. 
 
You asked the Plan to pay for the EM services as billed. You say that this should be separately payable.  The 
Plan denied your request. The Plan says this is included in payment for the surgical procedure. 
 
Please note: We determined that the EM services were supported for separate payment from the surgical 
procedure as the EM services were in regard to a separate vein and not related to the surgery. This was 
correctly billed with modifier -25. As such, we reviewed whether the code itself was supported. 
 
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 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
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 the EM services as billed. Our reviewer says 
that the records do not support the EM code selected. Our reviewer found the documentation does not support 
the requisite level of medical decision making, nor the amount of time spent to justify this code.  
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the office evaluation and management (EM) provided on November 16, 2022, 
billed with code 99213.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-compounded foam (NCF) sclerotherapy, for 
treatment of other incompetent extremity veins (36471). 
 
You asked the Plan to pre-approve bilateral sclerotherapy. You say that the requested treatment is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested bilateral sclerotherapy is 
not medically necessary and cannot be approved.  
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for tributary treatment such as sclerotherapy to be considered medically necessary per coverage 
criteria, there needs to be persistent significant symptoms following successful treatment of truncal (saphenous) 
reflux with these symptoms existing more than 6 weeks after the reflux was treated and despite conservative 
efforts. Additionally, the veins to be treated need to be at least 4 mm in diameter (this criterion is met). As the 
enrollee has not yet undergone saphenous vein reflux treatment, the above criteria have not been met. The 
health plan does not provide for simultaneous saphenous reflux treatment and tributary treatment.  A rationale 
for this is that many patients experience satisfactory relief with the truncal intervention alone. As this is a 
reasonable position, and the documentation does not identify any unique characteristics that would necessitate 
simultaneous tributary and saphenous vein treatments, unable to overturn the health Plan determination on the 
basis of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral sclerotherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent 
extremity veins (36471).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. The Plan denied your request. The Plan says 6 
additional physical therapy visits is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found there is no evidence of the enrollee's response to prior 
therapy and the need for continued therapy. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for procedure code 97750. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 97750 is bundled into payment for code 97530. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  
 
In this case, we have confirmed that code 97750 is a column II code to column I code 97530. The medical 
records provided do not show that code 97750 billed with the -59 modifier is a distinct procedural service. 
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 97750 billed for date of service December 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have various 
upcoming medical/dental appointments for which you require additional trips for your routine transportation 
benefit. The Plan denied your request. The Plan says additional 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 72 trips per year. 
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
sixty-nine (69) one-way transportation trips out of the allowed seventy-two (72) one-way trips approved. Once 
72 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve ten (10) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99223) provide on February 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the provider needs 
to bill the corresponding Initial Observation Care code 99218  99220. 
 
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 99223 is "Initial hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making. When using total time on the date of the encounter for code selection, 75 minutes must be met or 
exceeded". 
 
We find that CPT code 99223 is supported in the medical record. Specifically, code 99223 can be used to 
represent initial hospital inpatient or observation care. As such, it is appropriate to report code 99223 for the 
services provided in this case. Based on this information, we decided that Medicare rules for coverage of the 
services have been met. Therefore, we decided that the Plan has to pay for the services (99223) provide on 
February 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service December 28, 2022. 
 
You asked the Plan to pay for code 99215. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 99215 is not supported by the medical record. The records do 
not support a high level of medical decision making or the total time required of the code 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. 
 
In this case, the CPT Code Manual definition of code 99215 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 4054 minutes of total time is 
spent on the date of the encounter. 
 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 code 99215. Our reviewer says that code 99215 is not 
supported by the medical record. Our reviewer found the patient is a 61-year-old female who was treated in an 
outpatient facility for a checkup for opioid use disorder which was uncomplicated according to the notes. The 
patient was stable, and the checkup was routine and unremarkable otherwise. Drug screening was ordered, and 
medications were continued. Code 99215 was billed. However, code 99215 is not supported by the medical 
record as the records do not sufficiently support a high level of medical decision making or a specific 
documentation that the visit took at least 40 minutes as required.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99215 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99215 billed for date of service December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc NP (0627T). 
 
You asked the Plan to pre-approve Via Disc NP. 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 Via Disc NP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy at this time. Therefore, the request is deemed not 
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 Via Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Via Disc NP (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and a sealed 
battery (E2365). 
 
You asked the Plan to pre-approve a power wheelchair and a sealed battery. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and a sealed 
battery. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the 
enrollee is not at high risk for skin breakdown, does not use a catheter, does not have spasticity, and does not 
require an alternative power control. As the power wheelchair base is not medically necessary, the requested 
sealed battery is not covered. 
 
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 power wheelchair and a sealed battery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and a sealed battery 
(E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes M17.11 and 
M17.12. Since the bilateral diagnosis code M17.0 exists in this case, it should be reported instead of the left-
sided and right-sided codes. 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 the services provided 
on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for tooth #12 and #13 provided on 
January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you sent in x-rays and would like for the dental 
procedures to be paid. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the core buildup is not covered by the Plan. 
 
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 core 
buildup (D2950) for tooth #12 and #13 provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110), a partial upper denture (D5213), and a 
partial lower denture (D5214) provided by an out-of-network provider on December 13, 2022.  
 
You asked the Plan to pay for the dental services. You say that you are covered for $2,000 for dental services 
and you would like the Plan to review and send a check. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a cleaning (D1110), a partial upper denture (D5213), and a partial lower denture (D5214) provided 
by an out-of-network provider on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the iTind procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the iTind procedure is not medically reasonable and necessary in this case. The use of a 
temporarily implanted nitinol device (e.g., iTind) is considered investigational as a treatment of lower urinary 
tract symptoms due to benign prostatic hyperplasia. Further studies are needed to evaluate the durability of 
iTIND outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate the advantages of second-generation device over the first device. ITind is not recommended in the most recent 
guidelines. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the iTind procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external counterpulsation (ECP) therapy. 
 
You asked the Plan to pre-approve ECP therapy. You say that the enrollee needs this therapy. The Plan denied 
your request. The Plan says medical criteria for the requested service have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab 
programs. The services must be provided in a doctors office or an outpatient hospital setting.  
 
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 ECP therapy. Our reviewer says that 
this service is not medically necessary. Our physician reviewer found documentation does not indicate that 
optimal anti-anginal therapy has been implemented. As such, it is premature to consider ECP.  In summary, 
there is insufficient documentation to support the medical necessity for the use of ECP in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ECP therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve external counterpulsation (ECP) therapy.