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

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. The Plan denied your request. The Plan 
says a power seat elevation system is a non-coverable item. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960-XU billed for date of service 
December 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is not inclusive of any other services on 
this date.  The Plan denied your request. The Plan says the code cannot be separately reimbursed.  
 
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 92960 is cardioversion, elective, electrical conversion of 
arrhythmia; external. We find that CPT code 92960 is not separately payable in this case. The records do not 
show that code 92960 was an unusual, non-overlapping service from the other cardiovascular services 
provided. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 92960-XU billed for 
date of service December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81529 billed for date of service August 22, 
2022.  
 
You asked the Plan to pay for procedure code 81529. You say that this service is supported in the medical 
record. 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 81529 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 81529 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 81529 billed for date of service August 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve Intracept procedure . You say that you are appealing the wrongful denial for 
intraosseous ablation of the basivertebral nerve which is accomplished with the Intracept procedure. The Plan 
denied your request. The Plan says there is not enough proof that shows this procedure is as safe and as 
effective as other standard treatment options.  
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the records do not contain a magnetic resonance imaging (MRI) that shows only 
modic endplate changes without facet degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 20, 
2023. 
 You asked the Plan to pay for procedure code 88104. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 88104 is bundled into payment for code 
88112. 
 
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 88104 
is a column II code to column I code 88112. 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 88104 billed for date of service January 20, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 21, 2022, to December 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee had to stay 
in the hospital due to the surgeon perforating their colon during surgery. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $205 copayment per day, for days 1 to 6 and a $0 copayment per day, for days 7 and beyond for 
each medically necessary inpatient stay.  
 The enrollee has been asked to pay a $205 copayment per day, for days 1 to 4 of the inpatient hospital stay. The 
enrollee has been asked to pay a total of $820 ($205 copayment x 4 days = $820). The enrollee has not been 
charged for any additional days. This item/service falls within the inpatient hospital care benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the inpatient hospital stay provided from December 21, 
2022, to December 25, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's care needs. The Plan denied your request. The Plan says the enrollee's therapy needs can be met in a 
lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such a skilled 
nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 8, 2022, to May 19, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had already met 
your out-of-pocket maximum 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 $235 
copayment per day for days 1-7 of each in-network inpatient hospital stay. Your contract with the Plan also 
says that enrollees then pay a $0 copayment for days 8-90 of the same inpatient hospital stay. 
 
The records show your out-of-pocket maximum was processed correctly. Due to meeting your out-of-pocket 
maximum, you have only been asked to pay $192.27, which is less than the standard $235 copayment. This 
item/service falls within the inpatient hospital care 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 
copayment for the inpatient hospital stay provided from May 8, 2022, to May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft for repair of peri-implant defect (D6103), 
and an immediate upper partial denture (D5221). 
 
You asked the Plan to pre-approve a bone graft for repair of peri-implant defect, and an immediate upper 
partial denture. You say that you need these services. The Plan denied your request. The Plan says the services 
at issue are not covered 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 pre-approve a 
bone graft for repair of peri-implant defect (D6103), and an immediate upper partial denture (D5221).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation beyond the 50-mile limit. 
 
You asked the Plan to pre-approve routine transportation beyond the 50-mile limit. You say that it is not your 
fault that the trip you need is over the mileage, but you still need transportation. The Plan denied your request. 
The Plan says routine transportation trips cannot exceed 50 miles. 
 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 routine transportation when routine transport, but each one-way trip cannot exceed 50 
miles.  
 
We looked at your request, the records in the case file, and the rules. 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 routine transportation beyond the 50-mile limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment (D5862), upper and lower 
overdentures (D5863, D5865), alveoloplasty (D7320) and guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve precision attachment (D5862), upper and lower overdentures (D5863, 
D5865), alveoloplasty (D7320) and guided tissue regeneration (D4266). You say that you have lost more than 
15 pounds since you can't eat properly because your dentures are too big for your mouth. The Plan denied your 
request. The Plan says the services are non-covered codes under your dental benefit. 
 
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 pre-approve 
precision attachment (D5862), upper and lower overdentures (D5863, D5865), alveoloplasty (D7320) and 
guided tissue regeneration (D4266).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the procedure. You say that you are appealing for the wrongful denial for 
intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The Plan 
denied your request. The Plan says this procedure is considered experimental and investigational, and the 
procedure has not been shown to be helpful. 
 
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 there is no magnetic resonance imaging (MRI)showing only modic endplate changes without 
evidence of foraminal stenosis or facet degenerative joint disease (DJD).  
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 Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items are 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case.  Our physician reviewer found that the enrollee's left upper-extremity strength and 
functional ability as evidenced by being independent for feeding should be sufficient to control any power 
options on the wheelchair through their own switches. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total of 16 (8 were approved) physical therapy (PT) 
sessions. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee would benefit from further 
services to decrease risk for future falls and to maximize their safety and independence. The Plan denied your 
request. The Plan says more skilled treatment is not needed at this time. 
 
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 therapy services. 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 the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee 
has had prior extensive therapy approved, and the documentation does not reveal that the enrollee requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total of 16 (8 were approved) physical therapy (PT) sessions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 17, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the documentation supports medical 
necessity.  The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
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 81345 is a column II code to column I code 0089U. CPT code 81345 
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 
81345 billed for date of service January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services at the L3 level. 
 
You asked the Plan to pre-approve kyphoplasty services at the L3 level. You say that the records provided 
support the need for the requested services which remain in dispute.  The Plan denied your request. The Plan 
says the criteria for coverage are not met for level L3.  
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty services may be considered reasonable 
and necessary for enrollees who meet the criteria referenced in the Medicare rules section.  
  
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 kyphoplasty services at the L3 level. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the magnetic 
resonance imaging (MRI) dated January 20, 2023, shows a new concavity of the inferior aspect of the L3 
vertebral body with edema, compatible with subacute endplate fracture. The exam indicates the pain has been 
present since December of 2022. The L3 compression fracture would no longer be considered an acute or 
subacute fracture at this time. The enrollee does note that her pain level is 10/10; however, she is not 
hospitalized, does not have detailed evidence of worsening pain, progression of vertebral body height loss, 
more than 25% body height reduction or kyphotic deformity corroborated by the documentation provided for 
review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty services at the L3 level have not been met. Therefore, we decided 
that the Plan does not have to pre-approve kyphoplasty services at the L3 level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) provided on January 24, 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 a pontic 
(D6245) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the complete upper denture (D5110) and the partial lower denture 
(D5212). 
 
You asked the Plan to pre-approve the complete upper denture (D5110) and the partial lower denture (D5212). 
You say that you are attempting to get your dentures. The Plan denied your request. The Plan says that the 
benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not send evidence showing that the Plan had previously paid for 
dentures. This means we are unable to confirm that the benefits have been exhausted. Therefore, we decided 
that the Plan has to pre-approve the complete upper denture (D5110) and the partial lower denture (D5212). 
 
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.