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

 
We decided that the Plan does not have to pay for the unlisted ambulance services coded A0999 provided on 
April 12, 2020. 
 
You asked the Plan to pay for the unlisted ambulance 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 payable. 
 
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 A0999 is unlisted ambulance service. 
 
We find that CPT code A0999 is not supported in the medical record. Specifically, the documentation does not 
support what this code actually represents since it is unlisted. In addition, payment under the ambulance fee 
schedule represents payment in full for all services, supplies, and other costs for an ambulance transport service 
furnished to a Medicare enrollee. Additional reimbursement for PPE and decontamination of the vehicle is 
included in the Medicare ambulance fee schedule. Based on this information, we decided that Medicare rules 
for coverage of the unlisted ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for the unlisted ambulance services coded A0999 provided on April 12, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the resin-based composite (D2393). We decided that the Plan does 
not have to pre-approve the upper partial denture (D5213).  
 
You asked the Plan to pre-approve the resin-based composite (D2393) and the upper partial denture (D5213). 
You say that you have been getting different answers on what is covered and not covered. You say that you 
need this dental work done. The Plan says that the filling is not medically necessary, and the upper partial 
denture is not a covered benefit. 
 
We decided that the Plan has to pre-approve the resin-based composite (D2393).  
 
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 resin-based composite. Our 
reviewer says that the criteria for coverage has been met. Our reviewer says that tooth #20 appears to have 
caries needing restoration, and a resin-based composite is medically reasonable and necessary. Therefore, we 
decided that the Plan has to pre-approve the resin-based composite.  
 
We also decided that the Plan does not have to pre-approve the upper partial denture (D5213). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested upper partial denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the upper partial denture. 
 
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-approvea stair lift.You asked the Plan to pre-approvea stair lift. You say that your current stair lift is broken and you need it to reach the second floor of your home.The Plan denied your request. The Plan says this is not covered.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea stair lift.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for enrollees with a 
personal history of specific cancers. 
 
We looked at the file and Medicare rules. The file shows that the enrollee does not have a personal history of 
cancer. 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 pre-approve BRCA genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide hypnotherapy. 
 
You asked the Plan to provide hypnotherapy. You say that you need hypnotherapy for smoking cessation. The 
Plan denied your request. The Plan says hypnotherapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover hypnotherapy for the diagnosis code of tobacco 
use. Therefore, we decided that the Plan does not have to provide hypnotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that  The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a seat lift chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2019 to August 
19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 August 5, 2019 
to August 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient hospital services provided to the enrollee on April 3, 2020, and April 4, 2020.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee would havebeen able to been managed at a lower level.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee did not have sufficient signs and symptoms suggestive of ACS or other cardiac abnormality to warrant inpatient services. He was hemodynamically stable and could have been treated at a lower level of care such as observation status. 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 not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient hospital services provided to the enrollee on April 3, 2020, and April 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of lumbar 
pain. The requested spacer is considered experimental, as more research is needed to show its safety and 
efficacy. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to the enrollee by an out-of-network provider 
on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided July 26, 2019 to August 22, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a corrected claim is needed before services can be paid. 
 
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 billed services are not supported in the medical record. Specifically, the claim was submitted 
with an inpatient discharge code, however, outpatient services were billed. Based on this information, we 
decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient services provided July 26, 2019 to August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the fillings provided on May 12, 2020. 
 
You asked the Plan to pay the in network rate for the dental services. You say that the 50% out of network 
coinsurance was applied to your dental account. You say that you were advised in February 2020 by a plan 
representative that the dentist was in network. You say that you were never advised that the dentist's status 
changed to out of network. You also say that the services should be covered with full benefits. The Plan denied 
your request. The Plan says 2 filling per calendar year are covered. The Plan says that the frequency limit has 
been exceeded. The Plan also says that due to a miscommunication a 1 time exception has been granted for the 
filling to be processed at the in network rate. 
 
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 frequency limit of 2 fillings per 
calendar year has been exceeded. The record shows that the Plan paid for 1 filling that you received on March 
12, 2020 and 1 for this date of service, thus exhausting the benefit. Therefore, we decided that the Plan does 
not have to pay the in network rate for the fillings provided on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve these services. You say that you need the chair to avoid falls. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup. 
 
You asked the Plan to pre-approve core buildup. You say that the dentist didn't know what you would need 
until he examined the tooth. You say that you want this covered. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient diagnostic testing and 
specialist office visit provided on May 5, 2020. 
 
You asked the Plan to waive the copayments for the outpatient diagnostic testing and specialist office visit. 
You say that you feel you should not be responsible for this cost share amount and you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says you received non-radiological diagnostic 
testing and specialist services on the date of service at issue in this appeal. The Plan says that the correct cost 
share has applied per your contract with the Plan. 
 
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 $20 
copayment for Medicare-covered non-radiological diagnostic services and a $20 copayment for specialist 
visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received non-radiological 
diagnostic testing on May 5, 2020. You have been asked to pay a $20 copayment for the outpatient diagnostic 
testing. The outpatient diagnostic testing falls within the Outpatient diagnostic tests benefit category. The file 
also shows you received services provided by a specialist on May 5, 2020. You have been asked to pay a $20 
copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit 
category. This means that you have been asked to pay the correct amounts 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 copayments for the outpatient diagnostic testing and 
specialist office visit provided on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services that you received from March 5, 2019 to 
August 18, 2019. 
 
You asked the Plan to pay for the dental services. You say that the dental work you received was the result of 
your accident. You say that you received letters from Maximus that said they were dismissing the case because 
the plan agreed to pay for the services. The Plan denied your request. The Plan says the services you received 
are dental in nature. The Plan says there is a maximum annual benefit of $500 for non-Medicare covered 
preventive and comprehensive dental services. The Plan also says that the maximum annual benefit has been 
exhausted. 
 
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 the services you received are dental 
in nature, the maximum annual benefit has been exhausted. The record shows that the plan paid $500 towards 
the bone replacement graft for ridge preservation that you received on March 5, 2019, thus exhausting the 
maximum annual benefit. Additionally, the record shows that the letters from Maximus were in regards to 
services that you received in 2018. Therefore, we decided that the Plan does not have to pay for the dental 
services that you received from March 5, 2019 to August 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lantus. 
 
You asked the Plan to pre-approve Lantus. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 6, 
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 the records do 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 the denied codes is: 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065). 
 
You asked the Plan to pre-approve the dental service. You say that you are on disability. You say that you need 
dental work. You say that you have had this dentist for about 10 years. The Plan denied your request. The Plan 
says the provider in this case is not a network provider. The Plan also says that care rendered by a provider that 
is not part of our supplemental dental network is not covered. 
 
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, you need to use a provider that is 
contracted with our dental vendor to provide supplemental dental services. Therefore, we decided that the Plan 
does not have to pre-approve an implant supported crown (D6065).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion administrative services provided from 
April 2, 2020 to May 14, 2020 billed with code S9328. 
 
You asked the Plan to pay for the home infusion administrative services. You say that this code is for infusion 
therapy via an implanted pump and is denied in error per Medicare guidelines. The Plan denied your request. 
The Plan says Medicare does not pay for services billed with this 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. 
 
Code S9328 has a status indicator of "I" on the Physician Fee Schedule, meaning that it is invalid for Medicare 
billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion 
administrative services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home infusion administrative services provided from April 2, 2020 to May 14, 2020 billed with code S9328.