Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 14, 2020 
 
You asked the Plan to pay for the non-emergency transportation. You say that the transport was medically 
necessary. The Plan denied your request. The Plan says you did not request prior authorization for the transport 
to the skilled nursing facility and network providers are available. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. You did not request prior authorization and services could have been 
provided in network. Based on this information, we decided that Medicare rules for coverage of the non-
emergency transportation have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided on January 14, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an X-ray of the hip (73502) performed on 
July 29, 2020. 
 
You asked the Plan to waive the deductible for an X-ray of the hip. You say that the assessed charge is too high 
for a 20-minute visit. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for each basic imaging service.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category "Outpatient 
diagnostic tests and therapeutic services and supplies." The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for each basic imaging service. This cost-sharing is a 
contractual obligation that had not been met at the time an X-ray of the hip was received on July 29, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for an X-ray of the hip (73502) 
performed on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, diagnostic procedure, and 
biopsy of oral tissue provided on June 23, 2020, and July 7, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, diagnostic procedure, and biopsy of oral tissue. You 
say that these services were not provided due to a dental issue. The Plan denied your request. The Plan says 
you are not eligible for these services. The Plan also says that you do not participate in the Plan's optional 
comprehensive dental coverage, and Plan dental benefits are not applicable for you. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, 
diagnostic procedure, and biopsy of oral tissue provided on June 23, 2020, and July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a rapid desensitization procedure (95180) 
performed on May 26, 2020. 
 
You asked the Plan to waive the coinsurance for a rapid desensitization procedure. You say that the Plan should 
reconsider this cost-sharing. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for administration of Medicare-covered Part B drugs.  
 
You have been asked to pay $88.10, or 20% of the Plan-allowed amount of $440.49, for a rapid desensitization 
procedure. A rapid desensitization procedure falls within the "Medicare Part B prescription drugs" 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 coinsurance for a rapid desensitization procedure (95180) 
performed on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided to the enrollee on February 25, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159 and 80173. 
 
You asked the Plan to pay for testing provided to the enrollee. You say that this claim should be paid. The Plan 
denied your request. The Plan says while a portion of this claim was paid, the Plan notes that blood specimen 
collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the 
remaining billed services cannot be verified. The Plan states multiple attempts were made to obtain additional 
information from the provider.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed due to an issue with the type of specimen reported (i.e. blood versus urine). Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for testing provided to the enrollee on 
February 25, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring provided on 
February 10, 2020. 
 
You asked the Plan to pay for intraoperative neurophysiology monitoring. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the parent code has been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. An add-on code is eligible for payment only if 
one of its primary codes is also eligible for payment. The required primary service code is denied in the claim 
processing system therefore; this service cannot be reimbursed separately. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
intraoperative neurophysiology monitoring provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76102) provided April 9, 2019. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76102 is Radiologic examination, complex motion (ie, 
hypercycloidal) body section (eg, mastoid polytomography), other than with urography; bilateral . 
 
We find that CPT code 76102 is not supported in the medical record. Specifically, no radiology report for the 
dates of service at issue was provided in the records. The plan made multiple attempts to obtain the requested 
documentation. Based on this information, we decided that Medicare rules for coverage of the radiology 
services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services 
(76102) provided April 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and requires less than an additional 25 days of 
acute care services, based on the recent notes. The enrollee does not require services at the LTACH that are not 
already available at the current setting. There are no services at the LTACH that the patient enrollee that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered soon once 
further improvement and stability is noted. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-ray provided on June 10, 2020. 
 
You asked the Plan to pay for the additional intraoral x-ray. You say that you were informed a dental exam and 
cleaning were covered semi-annually. You say that you got a bill for $255 and need help. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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, you also have a maximum benefit of 
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 10, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-
ray provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (E2620, E2377, E2313, 
E2311) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not need to operate 3 or more powered seating actuators through the drive 
control, a separate display (i.e., for alternate control devices)other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. The 
enrollee's strength and functional ability is sufficient to control any power options through their own individual 
switches. The enrollee is noted to be independent in dressing, grooming, hygiene, toileting. There are no 
significant postural asymmetries. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (E2620, E2377, E2313, E2311) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening lab services (87798, 87801, 87150, and 87481) 
provided to the enrollee on May 19, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says screening services of this type are not covered under Medicare. The Plan follows 
Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are 
not covered. The services billed were requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening lab 
services (87798, 87801, 87150, and 87481) provided to the enrollee on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 26, 2020 to 
February 27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you strongly disagree with this 
determination as the services rendered were both reasonable and medically necessary at the inpatient level of 
care. The Plan denied your request. The Plan says that the inpatient level of care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found an elderly patient presenting with an acute lower extremity deep vein thrombosis is reasonably 
expected to stay at least two midnights. The records support this hospitalization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 26, 2020 to February 27, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee 
on March 10, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is "critical care visit of 30-74 minutes." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
records do not document the time spent providing the critical care. CPT 99291 is reported by time spent 
providing critical care to a patient.  Therefore, this code cannot be verified. 
 
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 pay for critical care services (CPT 99291) provided to the enrollee on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 12, 
2018. 
 
You asked the Plan to pay for this service. You say that this claim should be paid.  The Plan denied your 
request. The Plan says this claim was not filed within the one-year limit for Medicare claims.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for this 
service was not filed until May 18, 2020. This means that more than one calendar year from the date of service 
had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician 
services provided to the enrollee on April 12, 2018.
Appeal type: Testing
Decision: Favorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy for the enrollee.You asked the Plan to pre-approve this procedure. You say that this procedure was medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria were not met.Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct LCD criteria. Our Medical Director looked at the case file and the reopen request. At issue is coverage for Wireless Capsule Endoscopy (WCE).The Maximus Physician Reviewer determined that the use of capsule endoscopy to evaluate for small bowel tumors distal to the duodenum in this gentleman with known history of pre-cancerous GI pathology is medically appropriate, medically necessary, and meets accepted procedure indications as provided.The Plan requested a reopen and stated the LCD clearly stated this procedure is not indicted for evaluation of small bowel neoplasm. The Plan is correct in this case. The documentation does not support that the enrollee in this case has Lynch syndrome, Peutz-Jeghers syndrome, or another polyposis syndrome affecting the small bowel. The coverage criteria for wireless capsule endoscopy have not been met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea wireless capsule endoscopy for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy (19081) performed on June 
11, 2020. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you wish to appeal this 
copayment. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $45 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $45 copayment for a breast biopsy. A breast biopsy falls within the 
"Physician/Practitioner services, including doctor's office visits" 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 a breast biopsy (19081) performed on June 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nasal endoscopies (31296, 31297) provided on September 
26, 2019. 
 
You asked the Plan to pay for nasal endoscopies. You say that these are valid and correct codes. The Plan 
denied your request. The Plan says these codes should not be reported together. 
 
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 codes 
31296 and 31297 have a Column One/Column Two Correct Coding relationship and cannot be paid as billed. 
These codes cannot be paid as a separate line items. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for nasal endoscopies (31296, 
31297) provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 15, 2020. 
 
You asked the Plan to pay for the dental service. You say that the Evidence of Coverage states that you are 
entitled to an x-ray once per year. You say that the request was denied due to not using a "proper code". You 
say that your dentist did not want to use a code for a higher cost x-ray. You also say that this service should be 
covered. The Plan denied your request. The Plan says bitewing x-rays are not listed as a covered service. 
 
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 the 
bitewing x-rays (D0274) provided on July 15, 2020.  
 
Your complaint about the use of a 'proper code' is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from March 20, 
2020, to May 22, 2020 and billed under codes 97012 and 97110. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says therapeutic exercises are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Therapeutic exercises are not covered by Medicare 
in this setting. Therefore, we decided that the Plan does not have to pay for chiropractic services provided to 
the enrollee from March 20, 2020, to May 22, 2020 and billed under codes 97012 and 97110.