Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on February 18, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were informed that the x-rays would be 
covered as they were medically necessary. You also say that you cannot afford to pay any additional funds. The 
Plan denied your request. The Plan says 2 of either D0220, D0230, D0270, D0272, D0273 or D0274 are 
covered per 1 calendar year. The Plan says that the benefit for periapical and bitewing x-rays has been 
exceeded. 
 
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 benefit for periapical and bitewing 
x-rays has been exceeded. The record shows that the Plan paid for the initial periapical x-ray (D0220) and the 
additional periapical x-ray (D0230) that you received on this date of service. Therefore, we decided that the 
Plan does not have to pay for the bitewing x-rays (D0274) provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevated leg rests for a wheelchair.
You asked the Plan to pre-approve elevated leg rests. You say that elevated leg rests are necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for leg rests. 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 elevated leg rests. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates you ambulate with a walker. The documentation does not indicate you have a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or significant edema of the lower extremities that requires an elevating leg rest; or meets the criteria for and has a reclining back on a wheelchair. The documentation does not meet the criteria for elevating leg rests and elevating leg rests are not medically reasonable and necessary 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 elevated leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve elevated leg rests for a wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services with CPT codes 99152 and 
99153 provided on December 11, 2019. 
 
You asked the Plan to pay for CPT codes 99152 and 99153. 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. 
 
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 provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code is not supported in the medical record. Specifically, the medical record does not contain 
evidence that moderate sedation was performed with the presence of an independent trained observer.  
 
The review also shows that the medical records provided represent professional charges; however, procedure 
code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC 
Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation services with CPT codes 99152 and 99153 provided on 
December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services with CPT code 99152 provided on January 30, 2020.
You asked the Plan to pay for CPT code 99152. 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.
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 provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not contain evidence that moderate sedation was performed with the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of CPT code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services with CPT code 99152 provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical 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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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  
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device provided to the enrollee
during a facility stay on August 12, 2020.
You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim was submitted to the Plan in error.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. This equipment was used during and after a surgical procedure by the facility. Payment for this
service would have been included under the facility claim. Payment to you for this service is the responsibility
of the facility or hospital. Therefore, we decided that the Plan does not have to pay for pneumatic compression
device provided to the enrollee during a facility stay on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy with dental code D3310 provided on 
August 6, 2020. 
 
You asked the Plan to pay for dental code D3310. 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 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 
endodontic therapy with dental code D3310 provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 84443, 80061, 36415, G0103, 
85052, 85651, 86225, 86235, 86431) provided on September 14, 2020 by an out of network (OON) provider.  
 
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (80053, 84443, 80061, 
36415, G0103, 85052, 85651, 86225, 86235, 86431) provided on September 14, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a vision exam (99204) and fundus 
photography (92250) performed by an out of network provider on July 21, 2020. We also decided that the Plan 
does not have to pay for an eye refraction. 
 
You asked the Plan to waive the coinsurance for a vision exam and fundus photography and to pay for an eye 
refraction. You say that you are being charged more than you were told you would be. The Plan denied your 
request. The Plan says the correct coinsurance was applied for a vision exam and fundus photography, and that 
an eye refraction is not a covered benefit. 
 
Regarding the request to waive the copayment for a vision exam and fundus photography: 
 
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 50% 
coinsurance for each out of network Medicare-covered eye exam to diagnose and treat conditions and diseases 
of the eye.  
 
You have been asked to pay $80.31, or 50% of the Medicare-allowed amount of $160.61, for a vision exam, 
and $22.08, or 50% of the Medicare-allowed amount of $44.15, for fundus photography. A vision exam and 
fundus photography fall within the "Vision care (Medicare-covered)" 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 vision exam (99204) and fundus photography (92250) performed 
by an out of network provider on July 21, 2020.  
 
Regarding the request to pay for an eye refraction: 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers an eye refraction only when part of a routine, non-medical eye exam performed by a 
specified network provider. 
 
We looked at the file and the Plan's rules. The record shows that an eye refraction was performed as part of a 
medical, non-routine eye exam. Based on this information, we decided that the Plan's rules for coverage of an 
eye refraction have not been met. Therefore, the Plan does not have to pay for an eye refraction (92015) 
performed on July 21, 2020. 
 
Your complaint about receiving erroneous or ambiguous information about your cost-sharing responsibility 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: Favorable

We decided that the Plan has to pay for the infectious agent detection by nucleic acid (87631) provided on
June 25, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that respiratory infectious agent detection, code 87631, is non-covered by Medicare and therefore, excluded from coverage.
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 this service. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee presented to the emergency room on June 25, 2020 with a cough and dyspnea on exertion. He had been treated with steroids one month prior. He was evaluated with a history and physical exam, laboratory studies and a chest x-ray. Given his co-morbidities and the issues with the ongoing Covid-19 pandemic, the laboratory study: infectious agent detection by nucleic acid (87631) provided was medically necessary and reasonable. 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 been met. Therefore, we decided that the Plan has to pay for the infectious agent detection by nucleic acid (87631) provided on June 25, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $220 copayment charged for ambulance transport
provided on June 27, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan
denied your request. The Plan says while part of this claim which you are not responsible for was paid, the
$220 copayment is a contractual obligation.
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 $220
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 $220 copayment charged for
ambulance transport provided on June 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need additional 
routine transportation trips because of your medical conditions. The Plan denied your request. The Plan says 
the requested routine transportation trips exceed your annual benefit allowance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that your 24th trip for 
the 2020 calendar year is scheduled for December 30th at 10 am. Based on this information, we decided that 
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 20, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently in the hospital and were supposed 
to be discharged last week but cannot go home. The Plan denied your request. The Plan says the criteria for 
coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is noted to be experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the PILD procedure remains experimental. More research is needed to show safety and 
efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided lumbar decompression (PILD) procedure for the enrollee.