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

 
We decided that the Plan does not have to pre-approve core buildup services. 
 
You asked the Plan to pre-approve core buildup services. The Plan denied your request. The Plan says this 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 services are not among 
those covered under this benefit. The Plan only covers those dental services listed in the Evidence of Coverage. 
Core buildup services are not covered. Therefore, we decided that the Plan does not have to pre-approve core 
buildup services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from June 17, 2020, through 
June 18, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid because the services 
were emergency related. The Plan denied your request. The Plan says the Plan confirmed the place of service 
documented on the claim is 22-Outpatient Hospital and if services provided were emergency related, the non-
contracted provider would use the proper place of service to report emergency services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the medical services have not been 
met. The rules state that when completing the 1500 claim form, providers must enter the correct Place of 
Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. 
Therefore, we decided that the Plan does not have to pay for the medical services provided from June 17, 2020, 
through June 18, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (CPT Code 99226) provided on 
June 18, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that the claim should be paid because the services were 
emergency related. The Plan denied your request. The Plan says the Plan confirmed the place of service 
documented on the claim is 22-Outpatient Hospital and if services provided were emergency related, the non-
contracted provider would use the proper place of service to report emergency services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
rules state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) 
code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. Therefore, we 
decided that the Plan does not have to pay for subsequent observation care (CPT Code 99226) provided on 
June 18, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extractions (D7140) and a removable unilateral 
partial denture (D5284). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says extractions are not listed as a covered service. The Plan says a removable unilateral 
partial denture is not listed as a covered service either. 
 
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 the 
extractions (D7140) and a removable unilateral partial denture (D5284).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for autologous eye drops provided on June 18, 2020. 
 
You asked the Plan to hold you harmless for eye drops. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that medications that are not FDA approved will not be covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for eye drops by a contract provider. The file does not show that the Plan provided notice 
that eye drops would not be covered. Under Medicare rules, this means the eye drops are considered approved 
by the Plan. Therefore, we decided that the Plan has to hold you harmless for autologous eye drops provided on 
June 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transport trips. 
 
You asked the Plan to provide additional routine transport trips. You say that the provider is not crediting you 
for cancelled trips. The Plan denied your request. The Plan says you have one trip remaining according to 
records. 
 
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 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have almost exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transport trips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test. 
 
You asked the Plan to pre-approve the sleep test. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered for the above indications. 
 
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 sleep test. Our reviewer says that 
the requested home sleep test is not medically reasonable and necessary. Our physician reviewer found that the 
 
 
enrollee is a 62-year-old female who underwent a cardiology consult for the evaluation of severe bradycardia. 
She has history of hypertension, hyperlipidemia, abnormal EKG, chronic renal insufficiency, and family 
history of pacemaker placements. The guidelines support a sleep study when one of the following is met: 
Results are provided from a sleep questionnaire, such as an Epworth Sleepiness Scale, Berlin Questionnaire, 
STOP Bang Questionnaire or an Insomnia Severity Index, Apnea is witnessed and reported by a bed partner. In 
this case, a previous diagnosis of obstructive sleep apnea (OSA) was confirmed in the record. The clinical 
information provided does not meet these criteria. The review has determined that the requested home sleep 
test is not medically reasonable or necessary according to the coverage criteria established in the NCD. 
 
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 sleep test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home sleep test.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging (78452) 
provided on June 26, 2020. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you would like 
reconsideration because you do not believe you should be responsible for this amount. The Plan denied your 
request. The Plan says this claim processed correctly per your EOC. 
 
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 $275 
copayment for advanced imaging services.  
 
You have been asked to pay a $275 copayment for the myocardial perfusion imaging. The myocardial 
perfusion imaging falls within the 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 myocardial perfusion imaging (78452) provided on June 26, 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 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 
services are necessary. Our physician reviewer found based on the documentation provided, coverage criteria 
has not been 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a floor mat evaluation. 
 
You asked the Plan to pre-approve the floor mat evaluation. You say that you would like reconsideration 
because there is a risk of you falling when getting up in the night. The Plan denied your request. The Plan says 
the floor mat does not primarily service a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a floor mat evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for the evaluation and management of a new 
patient (99203) provided on July 8, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the services 
are supported by the medical record. The Plan denied your request. The Plan says the new patient code is not 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say to interpret the phrase "new 
patient" to mean a patient who has not received any professional services from the physician or physician group 
practice (same physician specialty) within the previous 3 years. 
 
In this case, the CPT Code Manual definition of code 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed 
examination; Medical decision making of low 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 severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family.  
 
We find that CPT code 99203 is not supported in the record. Specifically, the record indicates that this member 
 
 
received an evaluation and management service from a physician in the same group with the same specialty on 
June 14, 2020. Based on this information, we decided that Medicare rules for coverage of the office visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the office visit for the evaluation 
and management of a new patient (99203) provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulse oximeter. 
 
You asked the Plan to pre-approve the oximeter. You say that due to COVID-19 restrictions, it is medically 
necessary to be able to report and monitor oxygen saturations. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that pulse oximeters (E0445) are not a covered 
benefit.  
 
The requested item is statutorily not covered. Based on this information, we decided that Medicare rules for 
coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a pulse oximeter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage  of chiropractic service is specifically limited to treatment by means of manual 
manipulation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopies provided on March 18, 2020 and March 
23, 2020. 
 
You asked the Plan to pay for the colonoscopies. You say that the colonoscopies are considered complete. The 
Plan denied your request. The Plan says the CPT codes for the incomplete colonoscopies need -53 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -53 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records show the colonoscopies failed to reach the junction of the small intestine. Based on this 
information, we decided that Medicare rules for coverage of services billed without a -53 modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for the colonoscopies provided on March 
18, 2020 and March 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a dentist office visit (99204) on January 16, 2020, and a mouth lesion 
excision (40812) on January 31, 2020. 
 
You asked the Plan to pay for a dentist office visit and a mouth lesion excision. You say that per your 
understanding the services did not require pre-authorization from your primary care provider. The Plan denied 
your request. The Plan says that rules for payment have not been 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 a dentist office visit and a mouth lesion 
excision. Our reviewer says that the requested items/services are medical, rather than dental, in nature, and 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
presented with a lesion of the mouth that had no known traumatic cause. A lesion in the soft tissue showing a 
color/size change with no known cause should be properly evaluated. The same would be done for a lesion on 
the skin given similar circumstances. The services are medical in nature, as it is a surgical procedure to remove 
a soft tissue lesion and submit for biopsy the same as if there had been a skin lesion with a changed area that 
was suspicious. 
 
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 dentist office visit and a mouth lesion excision have been met. Therefore, we 
decided that the Plan has to pay for a dentist office visit (99204) on January 16, 2020, and a mouth lesion 
excision (40812) on January 31, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the abdominal x-ray provided on February 22, 
2020. 
 
You asked the Plan to pay for the x-ray interpretation. You say that the claim was corrected to reflect the Place 
of Service (POS) code 32, which is the nursing home POS. The Plan denied your request. The Plan says that 
this claim was originally denied for an improper POS code since the enrollee was a resident at a nursing home. 
The corrected claim updated the POS code but failed to update the service facility location in Field 32 of the 
claim form. Therefore, it still cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that, for physician interpretations of diagnostic 
testing, the location information reported in field 32 should reflect the location of that physician.  
 
In this case, the Plan has attested that they received a corrected claim where the POS code was changed from 
11 to 32, which was necessary since the POS code must reflect when an enrollee is in a nursing home. 
However, the claim was still denied stating that the location in Field 32 must reflect the address of the nursing 
home. According to the above referenced rules, the location reported in this field should reflect the address of 
the interpreting physician. As such, we find that the corrected claim is not deficient and that the Plan's denial 
rationale is not supported. Therefore, we decided that the Plan has to pay for the interpretation of the abdominal 
x-ray provided on February 22, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is a reasonable expectation to transition to a home exercise program at 
this point. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for your condition. You have had prior therapy for your neck and shoulder, and it does 
not appear that you require the ongoing unique  skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. You have been authorized additional sessions to review an independent exercise 
program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 19. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. 
The Plan denied your request. The Plan says core build up is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 19.