Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 skilled nursing visits. 
 
You asked the Plan to pre-approve 8 skilled nursing visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 8 skilled nursing visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve 
your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent 
deterioration. You have had prior skilled nursing for disease management and education. Your conditions are 
chronic and there is no evidence of complex wound care or other skilled nursing need. You were educated and 
are competent in wound care needs. The request for additional skilled nursing visits is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse up to the maximum amount for the extraction (D7210) 
provided on May 27, 2020 by the out of network provider. 
 
You asked the Plan to reimburse up to the maximum amount for the dental service. You say that when you 
were at the hospital you had tooth pain. You say that doctor advised they do not do dental extractions. You also 
say that the doctor advised they would provide a referral at discharge but never did. The Plan denied your 
request. The Plan says the dentist in this case is not a participating provider. The Plan also says services are 
only covered when received by a participating provider. 
 
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 and extractions are a covered service, 
dental services that are received by an out of network provider are not covered. Therefore, we decided that the 
Plan does not have to reimburse up to the maximum amount for the extraction (D7210) provided on May 27, 
2020 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for saline solution (J7030) provided on May 18, 2020. 
 
You asked the Plan to pay for saline solution. You say that the records support the billing of this code. The Plan 
denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the fluid used to administer drugs is incidental 
hydration and is not separately payable. 
 
We looked at the file and Medicare rules. The record shows that the saline solution at issue was used to 
administer other drugs. Based on this information, we decided that Medicare rules for coverage of saline 
solution have not been met. Therefore, we decided that the Plan does not have to pay for saline solution (J7030) 
provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on November 
21, 2019. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minuted was performed on the billed date of service The 
documentation does not include the time spent providing this service. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services coded 99291 provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on May 1, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the items billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator provided on May 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on May 4, 2020. 
 
You asked the Plan to pay for the wound care. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
wound care services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for wound care provided on May 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided to the enrollee on 
March 11, 2020. 
 
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of 
deliveries for these items does not have the same ship date as the billed date provided. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the durable medical equipment provided to the enrollee on March 11, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 9, 2020, to February 18, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you were never told that you had an 
inpatient copayment. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $295 
copayment per day for days 1 to 5 and $0 copayment for additional days for inpatient stay. This inpatient stay 
lasted 9 days, resulting in a copayment obligation of $1,475. 
 
You have been asked to pay $295 copayment per day for days 1 to 5 and $0 copayment for additional days for 
inpatient stay. Inpatient stay 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 an inpatient hospital stay provided from February 9, 2020, to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 5, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on December 31, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy Pump. 
 
You asked the Plan to pre-approve a Negative Pressure Wound Therapy Pump. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific criteria for this equipment. 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 Negative Pressure Wound Therapy Pump. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records 
provided do not provide sufficient information to support the medical necessity of NPWT and 20 wound 
dressing kits. 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 Negative Pressure Wound Therapy Pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy Pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
prophylaxis (D1110) provided on June 4, 2020 by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you have been to see this dentist before. You 
say that this dentist did change offices. You also say that you thought you would still be covered. The Plan 
denied your request. The Plan says the provider in this case is not a network provider. The Plan also says 
services are not covered when you receive them out of network. 
 
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 and oral exams and prophylaxis are 
listed as covered, dental services that you receive out of network are not covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
prophylaxis (D1110) provided on June 4, 2020 by the out of network dentist.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-skilled nursing and housekeeping services provided 
on December 4, 2019. 
 
You asked the Plan to pay for the non-skilled nursing and housekeeping services. You say that you were 
expecting someone from the home care facility to follow up with you after your surgery, but they did not show 
up.  You stated you paid a relative $600 to take care of your needs at home. The Plan denied your request. The 
Plan says the services provided were not skilled services, and are not covered by Medicare. The Plan also says 
that fees charged for care by your immediate relatives or members of your household is not covered under any 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-skilled nursing and housekeeping services 
 have not been met. Therefore, we decided that the Plan does not have to pay for the non-skilled nursing and 
housekeeping services provided on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right above the knee prosthetic leg to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve a right above the knee prosthetic leg. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by 
a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a right above the knee prosthetic leg to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has 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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and 
efficacy. It is not needed in this case. There is no instability documented. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 13, 
2019 to September 16, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis is missing or invalid. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
present on admission indicator with the diagnosis code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the inpatient hospital services rendered from September 13, 2019 to September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit (99442) provided on April 6, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an OON telehealth visit. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth visit (99442) provided on April 6, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on November 17, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on November 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 skilled nursing visits. 
 
You asked the Plan to pre-approve 6 skilled nursing visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 6 skilled nursing visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition 
and/or prevent deterioration. The enrollee has had prior skilled nursing for disease and medication management 
and education. The enrollee's conditions are chronic and there is no evidence of complex wound care or other 
skilled nursing need. The request for additional skilled nursing visits is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 skilled nursing visits.