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

 
We decided that the Plan does not have to pay for the paramedic intercept services you received on February 
19, 2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you don't believe you should be 
charged because you weren't transported anywhere and you don't recall being treated by a paramedic. The Plan 
denied your request. The Plan says paramedic intercept services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that does not have a contract with the volunteer ambulance company 
and these services were not rendered in a rural area. Therefore, we decided that the Plan does not have to pay 
for the paramedic intercept services you received on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with COVID-19 pneumonia complicated by acute respiratory failure requiring 
mechanical ventilation and acute myocardial infarction. He appears to be unstable and requires additional short 
term acute care services. He does not require services at the LTACH that are not already being provided at the 
current facility. There are no services at the LTACH that the patient requires that is not already available and 
covered at the current facility. The LTACH services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 need intense therapy to be able to get back to 
work. The Plan denied your request. The Plan says that your needs could be met at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF care. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
enrollee has reached her plan goals. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The documentation shows that the original request was for 4 home health physical therapy services. The plan 
has agreed to pre-approve 2 visits. 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 home 
health services. Our physician reviewer found that there is no documentation that skilled therapy services are 
required to effectively provide treatment in order to improve the enrollee's level of function, or to perform a 
maintenance program to maintain her level of function or prevent deterioration. The enrollee was discharged 
from physical therapy having met goals. She is walking 150 feet with supervision with a straight cane, and is at 
supervision for transfers with no further signs of progress in her function. Therefore, additional visits are not 
medically reasonable or 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you rely on the referring provider to obtain 
authorization, so if authorization was not obtained you should not be penalized for the error. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and the ordering provider is also out-of-network with the Plan. 
 
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 February 18, 
2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a CT scan of the head or brain (70450-26-77) performed on June 24, 
2020. 
 
You asked the Plan to pay for a CT scan of the head or brain. You say that the enrollee had multiple exams on 
this date of service. The Plan denied your request. The Plan says that the service was coded incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 70450-26-77 is supported in the medical record. Specifically, the record shows that this 
was a distinct service and was billed with Modifier 77 - indicating that the service had to be repeated by 
another physician. Based on this information, we decided that Medicare rules for coverage of a CT scan of the 
head or brain have been met. Therefore, we decided that the Plan has to pay for a CT scan of the head or brain 
(70450-26-77) performed on June 24, 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: Unfavorable

 
We decided that the Plan does not have to pay for the mammography screening (77067) and breast 
tomosynthesis (77063) provided on February 10, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for mammography and breast tomosynthesis. You say that the services were 
referred. The Plan denied your request. The Plan says prior authorization is required for non-emergent services 
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 mammography screening (77067) and breast 
tomosynthesis (77063) provided on February 10, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has had therapeutic effectiveness and 
tolerated well the Rhopressa medication in a recent trial. The Plan denied your request. The Plan says that this 
is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressa for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), 
prophylaxis (D1110), the bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on June 15, 
2020, by an out of network dentist. 
 
You asked the Plan to reimburse you for the dental services. You say that for dental preventive care there is a 
$0 copayment. You say that the Explanation of Benefits that you received shows that you must pay $175. You 
also say that you should be reimbursed the $175 that you paid to the provider. The Plan denied your request. 
The Plan says the provider in this case is not a network provider. The Plan says that this claim was processed 
according to providers are paid based on a maximum allowable charge (MAC). The Plan says for services 
covered under the plan, you may still be billed by an out of network provider for any amount greater than the 
MAC payment made by the plan to the provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services you received are listed 
as covered, you may be billed by an out of network provider for any amount greater than the maximum allowed 
charge payment made by the plan to the provider. Therefore, we decided that the Plan does not have to 
reimburse you for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the bitewing x-rays 
(D0274), and the panoramic x-ray (D0330) provided on June 15, 2020, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
May 20, 2020. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that the provider determined that 
using general anesthesia for this surgery was the best option for you due to a complex health history. The Plan 
denied your request. The Plan says fixed partial denture sectioning is not listed as a covered service. The Plan 
also says 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 pay for the fixed 
partial denture sectioning (D9120) provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on May 
4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that nursing facility was responsible for 
receiving prior authorization for their patients, not the doctor. The doctor provided services in good faith. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 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 domiciliary or rest home visit (99336) 
provided on May 4, 2020, by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on September 9, 
2019 to September 12, 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 95819 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 95819 is electroencephalogram (EEG); including 
recording awake and asleep. 
 
We find that CPT code 95819 is not supported in the medical record. Specifically, there is no documentation an 
EEG, including recording, for the billed dates of service. 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 electroencephalogram (EEG) rendered on September 9, 2019 to September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the shower chair and cane you received on 
April 2, 2020, and May 29, 2020. 
 
You asked the Plan to waive the coinsurance for the shower chair and cane. You say that you were never told 
there was a cost associated with this item. The Plan denied your request. The Plan says you were charged this 
coinsurance correctly. 
 
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 20% 
coinsurance for durable medical equipment and bathroom safety equipment.  
 
You have been asked to pay 20% coinsurance for the shower chair and cane. The shower chair and cane fall 
within the durable medical equipment and bathroom safety equipment benefit categories. 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 the shower chair and cane you received on April 2, 2020, and May 
29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services provided on February 13, 2020 billed with code 28308-51-RT.You asked the Plan to pay forthe billed services. You say that these services should all be paid as billed.The Plan denied your request. The Plan says the code 28308 is not supported in the record.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 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 billed services. Our reviewer says that the billed code is not supported in the medical record. Our coding reviewer found the enrollee is a female who received services on February 13, 2020 for Common Procedural Terminology (CPT) 28308: Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each.The operative report did not include documentation of an osteotomy with or without lengthening, shortening or angular correction to support CPT 28308.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 billed services have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services provided on February 13, 2020 billed with code 28308-51-RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth office visit (99442) provided 
on April 9, 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). Your contract with the Plan clearly says that you must pay a $10 
copayment for a primary care office visit.  
 
You have been asked to pay a $10 copayment for the telehealth primary care office visit provided. 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 the telehealth office visit (99442) provided on April 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of cataract with insertion of lens (66984) 
provided on May 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of cataract with insertion of lens. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of cataract with insertion of lens 
(66984) provided on May 4, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis (L4631) provided January 10, 2020. 
 
You asked the Plan to pay for ankle foot orthosis. You say that you billed for services for the work you 
completed for this custom fabricated device and is requesting payment since you did the work, but the enrollee 
did not show up to take delivery. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid itemized shipping/billing invoice and proof of delivery for the supplies 
provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies or proof of delivery. Of note, the submitted documentation indicates the patient 
did not appear to pick up the brace. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for ankle 
foot orthosis (L4631) provided January 10, 2020.