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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair, multiple power option 
(K0861) expandable controller (E2377) harness (E2313) electronic connection between 2 systems (E2311).   
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that you need the 
wheelchair to be mobile throughout the independent assisting living residence arrangement.  The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for the requested group 3 power wheelchair 
and the upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are 
not medically necessary.  
 
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 the power wheelchair and upgraded 
electronics. 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 limited endurance due to chronic 
obstructive pulmonary disease (COPD). The enrollee is able to stand independently and walk limited distances. 
The enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or 
require an alternative means of managing power drive. 
 
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 power wheelchair and upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a group 3 power wheelchair, multiple power option 
(K0861) expandable controller (E2377) harness (E2313) electronic connection between 2 systems (E2311).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 1, 2022, 
to November 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say the HHA enters a date of admission matching the From date on 
the first period of care in an admission. On subsequent periods of care, the HHA continues to submit the 
admission date reported on the first period of care. 
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from November 1, 2022, to November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
April 27, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says there is not enough 
information in the records provided to verify these unspecified procedure codes. 
 
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 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 procedure codes 83520 and 87798. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the laboratory report does not support 
"not otherwise specified" codes, as the procedures billed under these procedure codes are not documented, and 
therefore 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 procedure codes 83520 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service April 27, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the enrollee would benefit from 
this procedure. The Plan denied your request. The Plan says there is a missing psychological evaluation. 
 
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 a spinal cord stimulator trial. 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 psychiatric eval which is needed prior to stimulator placement. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MinuteMan Procedure at L4-L5. 
 
You asked the Plan to pre-approve a MinuteMan Procedure. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says this procedure is investigative/experimental. 
 
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 a MinuteMan Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 MinuteMan Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MinuteMan Procedure at L4-L5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and to pay more for 
an abutment support to crown (D6058) for tooth #30 provided on December 20, 2022. 
 You asked the Plan to pay for the dental services. You say that the enrollee had full benefits available, and the 
services should be paid. The Plan denied your request. The Plan says the denial of payment for the custom 
fabricated abutment is correct because it is not covered by the Plan. Also, the proper cost share was applied. 
 
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 total allowed amount for the abutment supported to crown (D6058) was $1,224 with a coinsurance amount 
of $918 ($1,224 total allowed x 75% coinsurance). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment is not 
among those covered under this benefit. The enrollee has been asked to pay a 75% coinsurance amount for the 
abutment supported to crown. This cost sharing is a contractual obligation the enrollee agreed to pay when they 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for a custom fabricated abutment 
(D6057) and to pay more for an abutment support to crown (D6058) for tooth #30 provided on December 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown and core buildup services for tooth #13 (D2740, D2950) 
provided on May 25, 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 that the services denied correctly as you do not 
meet the clinical requirements to be approved. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our physician reviewer 
found that the documentation provided meets the criteria for coverage for a core buildup (D2950) and crown 
restoration (D2740) for tooth #13. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pay for a crown and core buildup services for tooth #13 (D2740, D2950) provided on May 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2023, billed with 
codes 81162, 81272, 81292, 81321, & 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 31, 2023, billed with codes 81162, 81272, 81292, 81321, & 81351.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve  Synvisc. You say that the enrollee has knee pain that interferes with 
functional activities. The Plan denied your request. The Plan says that the step therapy requirements have not 
been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does 
not outline contraindications or reasons these medications were not considered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-rays, and pulp vitality 
tests (D0140, D0220, D0460) provided on June 15, 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 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 January 17, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-rays, and pulp 
vitality tests (D0140, D0220, D0460) provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on February 18, 2023, billed 
with evaluation and management (EM) code 99239. 
 
You asked the Plan to pay for the inpatient hospital care 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes 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 the inpatient hospital care provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the medical record does not include 
time spent with patient to verify service provided. 
 
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 inpatient hospital care provided have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided on February 18, 2023, billed with 
evaluation and management (EM) code 99239.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor system.  
You asked the Plan to pre-approve a Freestyle Libre 2 continuous glucose monitor system. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes 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 a Freestyle Libre 2 continuous glucose 
monitor system. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
record provided does not indicate that the enrollee is being treated with insulin or has problematic 
hypoglycemia. 
 
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 Freestyle Libre 2 continuous glucose monitor system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI, spinal canal. 
 
You asked the Plan to pre-approve an MRI, spinal canal. You say that the MRI of the lumbar spine is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for medical 
necessity. Most important, this provider is out-of-network and there are in-network providers available. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI, spinal canal. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding severe and/or progressive neurological abnormalities. Moreover, the treatment plan is 
conflicting with the request. The provider requested (on August 19, 2023) a computed tomography (CT) scan 
of the lumbar spine for possible surgical planning and this review is for a lumbar MRI. X-rays were noted; 
however, not dated, to show lumbar spondylosis at L5-S1; instrument intact. The documentation is not clear of 
when the previous MRI was performed and the findings of that study. There are limited large-scale, long-term 
references showing the medical necessity of the requested imaging study in this clinical setting. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the MRI is/was 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 an MRI, spinal canal have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI, spinal canal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800) 
 
You asked the Plan to pre-approve a power scooter. You say that you need this item in order to leave your 
house. The Plan denied your request. The Plan says the requested scooter is not coverable since it is only for 
use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800)
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on August 2, 2022, billed with 
procedure codes 81003, 87481, 87500, 87641, 87652, 87653, and 87798 (13 units). 
 
You asked the Plan to pay for the testing 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 codes. 
 
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 codes 81003, 87481, 87500, 87641, 87652, 87653, and 87798  
is urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 
protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 
(81003), candida species, amplified probe technique (87481), vancomycin resistance (eg, enterococcus species 
van A, van B) amplified probe technique (87500), staphylococcus aureus, methicillin resistant, amplified probe technique (87641), streptococcus, group A, quantification (87652), streptococcus, group B, amplified probe 
technique (87653), and infectious agent detection by nucleic acid (RNA or DNA), not otherwise specified, and 
amplified probe technique, each organism (87798). 
 
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the laboratory report describes 
multiple procedure codes. In this case, there is a more appropriate panel code that should be reported, which 
would include codes 87481, 87500, 87641, 87652, and 87653. Codes 81003 and 87798 are not supported by 
the documentation. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on August 2, 2022, billed with procedure codes 81003, 
87481, 87500, 87641, 87652, 87653, and 87798 (13 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601), delivery (A9901), and tax (S9999).  
You asked the Plan to pay for the CPAP device, delivery, and tax. You say that this should be covered. The 
Plan denied your request. The Plan says the records do not show the prior machine attempted repair. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CPAP device, delivery, and tax 
have been met. Theres no record showing the condition of the old CPAP, so we cant confirm there was 
irreparable wear or damage. Therefore, we decided that the Plan does not have to pay for the continuous 
positive airway pressure (CPAP) device (E0601), delivery (A9901), and tax (S9999).