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

 
We decided that the Plan does not have to pre-approve tooth removals (D7140) and dentures (D5110 and 
D5120). 
 
You asked the Plan to pre-approve tooth removals and dentures. You say that you cannot eat. The Plan denied 
your request. The Plan says these services are not covered by the Plan's dental 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. 
 
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 tooth 
removals (D7140) and dentures (D5110 and D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 7, 2023, billed with 
procedure codes 55700, 76872, and 76942-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed 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 55700, 76872, and 76942-59 is Biopsy, prostate; needle 
or punch, single or multiple, any approach, ultrasound, transrectal, and ultrasonic guidance for needle 
placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that a date that the service was provided 
was not documented on the procedure report and therefore cannot be verified. Provider signature does not 
support date of service procedure was performed. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 7, 2023, billed with procedure codes 
55700, 76872, and 76942-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health occupational therapy visits. 
 You asked the Plan to pre-approve the home health services. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented home health occupational therapy needs. The enrollee is independent with mobility 
and activities of daily living. Our reviewer found that as such, the requested home health occupational therapy 
services are not medically necessary or reasonable. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four home health occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 27, 2022, billed 
with procedure code 95937-26. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not  
 
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 95937-26 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that according to CPT rules, train of four 
is included in intraoperative neuromonitoring services and cannot be separately reported with 95937. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on December 27, 2022, billed with procedure 
code 95937-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2023, billed with 
codes 87486, 87541, 87581, 87651, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the plan's denial. 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 
April 20, 2023, billed with codes 87486, 87541, 87581, 87651, and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee currently has a power wheelchair that is less than five years old. 
 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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the current device is less than 5 years old and there is no evidence current device is not 
functional and meeting enrollee's needs. There is no documentation about the function of the current chair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a qualifying diagnosis for a group 3 power wheelchair which 
is causing a mobility limitation for which the wheelchair would be needed. 
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a PET scan of the brain.  
 
You asked the Plan pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted.  The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 pre-approve the PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is noted to have a cognitive 
impairment, but the etiology of said impairment is not clear. However, the records did not readily support that 
the diagnostic criteria for both AD and FTD have been satisfied. Therefore, the base requirement of the NCD 
would not be met. This would not meet the NCD criteria for coverage.  
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028, E2361, E2607, and E2620). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that this recommendation is the most appropriate and cost-effective option for meeting the enrollee's 
functional and medical needs. The Plan denied your request. The Plan says the enrollee does not have medical 
need for multiple power options included with K0861 group 3 power wheelchair. The Plan also says the 
electronic connection, harness, expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Our reviewer also 
found that although the enrollees condition may meet criteria for a PWC, the criteria for this specifically 
requested PWC with multiple power options including power tilt and recline are not met. 
 
 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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E0955, E1007, E1012, E1028, E2361, E2607, and E2620).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 13, 2022, 
to September 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
supported in the record, therefore the claim should be billed at the original DRG. The Plan denied your request. 
The Plan says A41.9 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with principal diagnosis A41.9, defined as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that principal diagnosis A41.9 is not supported in the 
documentation. Our physician reviewer found documentation shows the enrollee was afebrile, without 
tachycardia or leukocytosis. Although they were diagnosed with a urinary tract infection, the enrollee does not 
meet criteria for sepsis by the documentation provided, so code A41.9 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 13, 2022, to September 15, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87481, 87491, 87563, 
87653, 87798, 87641, and 87500. We decided that the Plan does not have to pay for the services described by 
procedure code(s) 87640.  
 
You asked the Plan to pay for procedure codes 87640, 87481, 87491, 87563, 87653, 87798, 87641, and 87500 
provided on March 6, 2023. You say that you would like the Plan to reconsider their denial of payment. The 
Plan says that procedure code 87640 is a column II code to column I code 87641 and cannot be paid separately. 
Procedure codes 87481, 87491, 87563, 87653, 87798, 87641, and 87500 are column II codes to column I code 
87801 and cannot be paid separately. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87481, 87491, 87563, 
87653, 87798, 87641, and 87500.  
 
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. Specifically, the Plan denied payment for procedure codes 87481, 87491, 87563, 
87653, 87798, 87641, and 87500 being included in payment for procedure code 87801. However, the file 
contains no evidence that procedure code 87801 was billed or paid for on the same date of service at issue in 
this appeal. The Plan provided no other rationale for the denial of payment for procedure codes 87481, 87491, 
87563, 87653, 87798, 87641, and 87500 and we must find in your favor. Therefore, we decided that the Plan 
has to pay for the services described by procedure code(s) 87481, 87491, 87563, 87653, 87798, 87641, and 
87500.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87640. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. The records provided do not support the billed 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 the services described by procedure code(s) 87640. 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028, E2359, E2607, E2615, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that a power wheelchair is required for the enrollee to be able to do all life tasks. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options available with 
K0861 group 3 power wheelchair. Expandable controller, harness and electronics are not medically needed. 
The Plan also says that power elevating leg rests are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the Group 3 power wheelchair with multiple 
power options is not medically necessary. Our physician reviewer found the documentation does not support 
that it is medically necessary to control the requested power options through the joystick (drive interface). The 
enrollee's right upper extremity strength and functional ability, as evidenced by being supervision for feeding, 
should be sufficient to control any power options through their own switches. Our reviewer also found that the 
enrollee does not require a ventilator or power tilt and recline seating. 
 
 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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E0955, E1007, E1012, E1028, E2359, E2607, E2615, and K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
power options (K0842) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, and E2603). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair with multiple power options and 
additional items and accessories. You say that you are requesting this denial be overturned for the overall 
health and welfare of the enrollee, and the items requested to be approved. The Plan denied your request. The 
Plan says as the enrollee does not have a need for both power tilt and power recline, the request for a group 2 
power wheelchair with multiple power options is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC (such as code 
K0842) is covered if certain criteria are met. Medicare rules also say if the PWC base is not covered, then 
related accessories will be denied. 
 
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 group 2 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found 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. Our reviewer also found that the enrollee does not require multiple power options.  
 
 
 
 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 group 2 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 2 standard power wheelchair with multiple power options (K0842) and additional items and 
accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, and E2603).