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

 
We decided that the Plan does not have to waive the copayment for an ambulance transport provided by a 
participating provider on February 27, 2020. 
 
You asked the Plan to waive the copayment for an ambulance transport. You say that you were treated poorly 
at the doctor's office prior to your transport. The Plan denied your request. The Plan says the correct copayment 
has been 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 $250 
copayment for ambulance services/ground.  
 
You have been asked to pay a $250 copayment for an ambulance transport. An ambulance transport falls within 
the ambulance services/ground 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 ambulance transport provided by a participating provider on February 27, 2020.  
 
We note your complaint about being mistreated at the doctor's office. Your complaint is a grievance that must 
be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cystourethroscopy (52332) provided to the enrollee on 
March 25, 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 Medicare billing criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We asked our 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the medical records provided do not support the services billed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for Cystourethroscopy (52332) provided to the enrollee on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on January 10, 2020 to March 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 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 office outpatient visit (99214) provided on January 10, 2020 to March 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower jaw bone graft (21215 RT, 21215 LT) provided. 
 
You asked the Plan to pay for a lower jaw bone graft. You say that the codes are well documented in the 
records. The Plan denied your request. The Plan says the medical records do not support billing the codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 a lower jaw bone graft. Our reviewer says 
that the billed services are not supported. Our physician reviewer found the medical records indicate the graft 
was obtained by means of a cadaver, therefore, the code description was not fully 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 lower jaw bone graft have not been met. Therefore, we decided that the Plan 
does not have to pay for a lower jaw bone graft (21215 RT, 21215 LT) provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 19, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy.
 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers with documented unresponsiveness to other clinical treatment over required four-week 
trial.  
 
The file does not show that the enrollee documented a trial of conservative therapy including exercise, 
elevation, and compression wraps. Therefore, we decided that the Plan does not have to pay for intermittent 
limb compression device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided on January 27, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee 
must pay a $285 copayment for each covered, one-way ambulance trip by ground or water.  
 
The enrollee has been asked to pay a $285 copayment for the one-way ground ambulance trip provided. This 
means that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0427) 
provided on January 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services (CPT 95940 and CPT 95955) 
provided to the enrollee on February 25, 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 billed codes cannot be verified. 
 
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 95940: 
 
continuous intraoperative neurophysiology monitoring in the operating room, in a one on one monitoring 
setting requiring personal attendance, for each 15 minutes (listed separately in addition to code for primary 
procedure) 
 
CPT 95955: 
 
electroencephalogram (EEG) during nonintracranial surgery (carotid surgery) 
 
We asked our coding 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 coding reviewer found the 
operative did not include documentation of one on one monitoring, therefore CPT 95940 cannot be verified. 
Documentation of EEG during nonintracranial surgery (carotid surgery) was not included in the technical 
report, and therefore, cannot be verified. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services (CPT 95940 and CPT 95955) provided to the enrollee on February 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient substance abuse hospitalization from April 18, 
2020 to April 19, 2020. 
 
You asked the Plan to pay for the inpatient substance abuse hospitalization from April 18, 2020 to April 19, 
2020. You say that the inpatient substance abuse hospitalization from April 18, 2020 to April 19, 2020 was 
medically necessary. The Plan denied your request. The Plan says the inpatient substance abuse hospitalization 
from April 18, 2020 to April 19, 2020 was 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 pay for the inpatient substance abuse hospitalization 
from April 18, 2020 to April 19, 2020. Our reviewer says that the inpatient substance abuse hospitalization 
from April 18, 2020 to April 19, 2020 was not medically necessary. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric/detoxification hospital on April 18, 2020 with Opioid 
Dependence with Withdrawal. Based upon review of the records provided it was not expected this enrollee 
would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or 
visual hallucinations, delusions and was not showing any behavioral issues. He was not undergoing any serious 
withdrawal symptoms as his COWS score was found to be mild. 
 
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 inpatient substance abuse hospitalization from April 18, 2020 to April 19, 
2020 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient substance 
abuse hospitalization from April 18, 2020 to April 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services (CPT 99291) provided to the enrollee on March 2, 2020, through March 5, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 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, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."We asked our coding 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 coding reviewer found documentationdoes not show the time spent with the patient. Therefore, CPT 99291 and time cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services(CPT 99291) provided to the enrollee on March 2, 2020, through March 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the ambulatory continuous glucose monitoring provided to the enrollee 
on May 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that as this enrollee is having low blood glucose, he would be expected to benefit from Libre use, which 
can help him see when he is going low. This should help adjust the insulin doses. The services are 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 the services have been met. Therefore, we decided that the Plan has to pay for 
the ambulatory continuous glucose monitoring provided to the enrollee on May 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are not able to use a walker. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all of the above criteria must be met for a power 
operated vehicle (K0800)  to be covered. 
 
We looked at the file and Medicare rules. The submitted medical records indicate that your home is not 
wheelchair accessible. The records also indicate that your limitation can be sufficiently and safely resolved by 
the use of a walker. Based on this information, we decided that Medicare rules for coverage of a power scooter 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #2. 
 
You asked the Plan to pre-approve the crown. You say that the x-rays do not show subcrestal caries. The Plan 
denied your request. The Plan says that there is a cavity below the bone of the tooth. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that a 
crown for tooth #2 is medically reasonable and necessary. Our physician reviewer found tooth #2 presently has 
a restoration and recurrent caries which has severely compromised the coronal integrity of the tooth. Our 
reviewer also found that a crown restoration is reasonable and necessary to return tooth #2 to proper function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2740) for tooth #2.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat CT scan of the left hip with MAKO protocol. 
 
You asked the Plan to pre-approve a repeat CT scan of the left hip with MAKO protocol. You say that the 
repeat CT scan of the left hip with MAKO protocol is medically necessary. The Plan denied your request. The 
Plan says the repeat CT scan of the left hip with MAKO protocol is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat CT scan of the left hip with 
MAKO protocol. Our reviewer says that the repeat CT scan of the left hip with MAKO protocol is not 
medically necessary. Our physician reviewer found the enrollee is with osteoarthritis of the left hip, and left hip 
arthroplasty is planned. The repeat CT scan is not medically needed. The MAKO assisted procedure remains 
experimental. It has not been shown to be better than open convention hip surgery. It is not medically necessary 
at this time. 
 
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 repeat CT scan of the left hip with MAKO protocol have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a repeat CT scan of the left hip with MAKO 
protocol.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says a second diagnostic medial branch block has not been completed. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found two sets of diagnostic medial branch blocks are required before a therapeutic block. Since these 
have not been performed yet, the request is considered not medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic facet injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2752) for tooth #27. 
 
You asked the Plan to pre-approve the crown. You say that tooth #27 has poor retention, and caries. The Plan 
denied your request. The Plan says that the x-rays provided do not show enough of the tooth. The Plan also 
says that the x-rays need to show the whole tooth above and below the gums. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the 
crown is medically reasonable and necessary. Our physician reviewer found tooth #27 has significant coronal 
breakdown. Our reviewer also found that a crown restoration is reasonable and necessary to prevent further 
breakdown and to restore the tooth to normal function 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2752) for tooth #27.  
 
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.