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

We decided that the Plan does not have to waive the $300 copayments ($600 total) for ambulance transport 
provided on July 10, 2020 and July 23, 2020. 
 
You asked the Plan to waive these copayments. You say that you would like at least one of these copayments 
waived. The Plan denied your request. The Plan says each copayment was charged based on your Plan contract 
agreement. 
 
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 $300 
copayment for each one-way ambulance transport. 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 $300 copayments ($600 total) for 
ambulance transport provided on July 10, 2020 and July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 8, 2020. 
 
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 testing is not covered. 
 
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 test at issue in this appeal was 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 the laboratory 
services rendered on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom heavy duty manual wheelchair. 
 
You asked the Plan to pre-approve a custom heavy duty manual wheelchair. You say that the requested custom 
heavy duty manual wheelchair is medically necessary. The Plan denied your request. The Plan says the 
requested custom heavy duty manual wheelchair does not meet criteria. 
 
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 custom heavy duty manual 
wheelchair. Our reviewer says that the requested custom heavy duty manual wheelchair does not meet criteria. 
Our physician reviewer found the requested custom heavy duty manual wheelchair is not medically necessary 
per Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). The documentation reveals 
that the enrollee has a personal mobility deficit but the wellness evaluation indicates that he is able to perform 
activities of daily living independently.  The enrollee's mobility deficit can be alleviated by the already 
authorized power mobility device. The documentation does not reveal that he requires an additional manual 
wheelchair as this would exceed his medical needs. 
 
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 custom heavy duty manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom heavy duty manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader and Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day Reader and Sensor. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered 
when the above criteria have been met. 
 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 
14 Day Reader and Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 Day Reader and Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating provider on May 10, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you shouldn't have to pay for 
this because all you had was a nasal swab. 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 $30 
copayment for urgently needed services/contracted.  
 
You have been asked to pay a $30 copayment for urgent care services. Since urgent care services were 
provided, the correct copayment has been applied. Urgent care services fall within the urgently needed 
services/contracted 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 urgent care services 
provided by a participating provider on May 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on June 4, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you fell, and the x-ray was 
medically necessary. The Plan denied your request. The Plan says this service has exceeded the frequency 
limitations in your dental benefit plan. 
 
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 are limited to four periapical x-
rays in a 12-month period. The record shows that you received 3 periapical x-rays on September 5, 2019, and 1 
periapical x-ray on March 3, 2020, and your periapical x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 7, 8, 9, and 10. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says core build 
up is not listed as a covered service. The Plan also say any services not listed are 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, 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 
build up (D2950) for teeth # 7, 8, 9, and 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that these services are available within your health plan 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 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 home ventilator to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on October 13, 
2019. 
 
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 should be submitted to Original Medicare. 
 
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 services provided to the enrollee on October 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 14, 2020 by a non-
network 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 a non-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 April 14, 2020 
by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora complete maxillary denture and a complete mandibular denture.You asked the Plan to pay forthe complete maxillary and mandibular dentures. You say that you are on a fixed income, and cannot afford a new set of dentures.The Plan denied your request. The Plan says these services are only covered 1 time in a 60 month time period. The Plan also says that you have already received these services in that time period.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For thatreason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a complete maxillary denture and a complete mandibular denture on May 19, 2016, and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pay fora complete maxillary denture and a complete mandibular denture
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found three subsequent PET scans have 
already been performed. Additional PET scans are not indicated. A CT scan of the chest would be more 
appropriate based on the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3330) 
for tooth #18. 
 
You asked the Plan to pre-approve core buildup (D2950) and endodontic therapy (D3330). You say that the 
enrollee needs a crown, core build and root canal therapy for tooth #18. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
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 (D2950) and endodontic therapy (D3330) for tooth #18.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on June 25, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you cannot financially afford this. 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 $175 
copayment for outpatient diagnostic tests/advanced imaging services.  
 
You have been asked to pay $116.90 which is less than your copayment amount of $175 for a CT scan. A CT 
scan falls within the outpatient diagnostic tests/advanced imaging services 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 CT scan provided by a participating provider on June 25, 2020.  
 
We note your complaint about not being able to afford this copayment. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on December 4, 
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 procedure code 99239 is 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of hospital discharge services spent on the enrollee. 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 hospital discharge services rendered on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on November 21, 
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 procedure code 99152 is 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 99152 is moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status. 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 moderate sedation services 
rendered on November 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on April 20, 2020.

You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration because this claim was billed was an appropriate diagnosis code. The Plan denied your request. The Plan says this claim was not billed with a valid primary diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Specifically, the diagnosis code billed is not supported by the record. Diagnosis code I26.90 indicates Sepsis. Per the notes, there is no record that the member was septic. Additionally, this diagnosis code requires an underlying infection to be coded first. An underlying infection has not been coded. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93010) provided on April 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe in-home evaluation and management (EM) services provided on October 22, 2019.You asked the Planto pay forthe EM services. You say that this evaluation was completed by a nurse practitioner and should be paid in full.The Plandenied your request. The Plansaysthere is no evidence that this enrollee was seen by a provider other than a licensed vocational nurse (LVN).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 99350 is Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making ofmoderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family.Wefind that CPT code 99350 is not supported in the medical record. Specifically, there is no evidence that an EM service was provided as only LVN services are documented. This code is not appropriate to report nursing services if a physician or other practitioner is not physically present. Based on this information, we decided that Medicare rules for coverage of the EM services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe in-home evaluation and management (EM) services provided on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on December 7, 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 not billed correctly. 
 
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 December 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the abdomen and pelvis (74176).You asked the Plan to pre-approvea CT scan of the abdomen and pelvis. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria hasnot been met.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 CT scan of the abdomen and pelvis. Our reviewer says that the services are medically necessary. Our physician reviewer found this enrollee would be very difficult to fully evaluate via telemedicine as she has innumerable clinical issues. That said, in such an enrollee with left lower quadrant pain the concern would be diverticulitis or intestinal ischemia or even obstruction. As such an ultrasound would not likely be of benefit as the concern would be bowel centered not of the upper abdomen. A CT of the abdomen and pelvis without contrast would be the most sensitive and non-invasive means with which to evaluate her.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of a CT scan of the abdomen and pelvis have been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the abdomen and pelvis (74176).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.