Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network dermatology services provided on August 6, 
2020.  
 
You asked the Plan to pay for this service. You say that the Plan should pay for these services. The Plan denied 
your request. The Plan says you did not have prior authorization for 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 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 out of network dermatology 
services provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, additional intraoral periapical x-ray, and extractions provided on June 23, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and 
extractions. You say that you confirmed with the Plan and the provider's office prior to the services being 
rendered, that the services were covered, and the provider was in-network. The Plan denied your request. The 
Plan says these services were performed by a provider who has chosen to opt out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, 
and extractions provided on June 23, 2020.  
 
Your complaint about being given misinformation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 3, 2020, and July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on July 3, 2020, and July 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the utilization of personal protective equipment and 
decontamination of the ambulance during and after ambulance services provided to the enrollee on April 10, 
2020. 
 
You asked the Plan to pay for these services. You say that  The Plan denied your request. The Plan says that 
this is not covered by Medicare. 
 
Medicare rules say that payment under the fee schedule for ambulance services covers both the transport of the 
beneficiary to the nearest appropriate facility and all items and services associated with such transport; and 
does not include a separate payment for items and services furnished under the ambulance benefit. The Plan 
follows the same rules. Therefore, we decided that the Plan does not have to pay for the utilization of personal 
protective equipment and decontamination of the ambulance during and after ambulance services provided to 
the enrollee on April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 19, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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, a cardiovascular risk panel, 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 forthe laboratory services rendered on May 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77525). 
 
You asked the Plan to pre-approve PBRT. 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. 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to enrollees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) (77525).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 16, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 21, 2020 
through June 9, 2020. 
 
You asked the Plan to pay for SNF care from May 21, 2020 through June 9, 2020. You say that the services 
rendered were medically necessary. The Plan denied your request. The Plan says continued assistance with 
routine daily activities could be safely provided at the custodial level of care as it had been before. The health 
plan has no added benefit for custodial care that goes beyond the Medicare benefit. We cannot provide 
coverage because there is no Medicare benefit or health plan added benefit for custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs and the beneficiary does not require skilled nursing or therapy services on a daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on May 21, 2020 through June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 20, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 15, 2020, to July 
20, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee could have been treated in a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found given the age and comorbidities of the enrollee it was reasonable to expect the hospitalization 
would last more than 2 midnights. Denial overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 15, 2020, to July 20, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 8, 2020 
to July 11, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from July 8, 2020 to July 11, 2020 was medically necessary. The Plan denied your request. The Plan says the 
inpatient hospital care provided from July 8, 2020 to July 11, 2020 was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided from July 8, 2020 to July 11, 2020 was not medically necessary. 
Our physician reviewer found the enrollee was directly admitted to the acute care hospital with bilateral upper 
and lower extremities resulting in an altered gait as well as a wound. Evaluation included laboratory studies, 
radiology imaging including ultrasound, magnetic imaging studies, wound cultures, and therapy evaluations 
and treatment. The enrollee was treated with intravenous antibiotics and intravenous fluids.  
 
 
It was determined ongoing hospital care was required. Therapy evaluation recommended no scheduled 
treatments. The enrollee declined the recommended lumbar puncture and arrangements for prolonged 
intravenous antibiotics were made. Care provided to the enrollee was observation level. There were no advance 
interventions or complex medical conditions. The enrollee had stable vital signs and no complaints at the time 
of admission. Inpatient care services were not supported by the documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 8, 2020 to July 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided February 17, 
2020. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says CPT code 99285 is not supported in the record. CPT 
code 99284 is more appropriate. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of 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 problems(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function for reimbursement 
consideration.  
 
We find that CPT code 99285 is not supported in the medical record. Specifically, documentation supports a 
moderate level of risk, therefore, CPT 99284 would be more appropriate to report. Based on this information, 
we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we 
decided that the Plan does not have to pay for emergency room services (99285) provided February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction procedure provided. 
 
You asked the Plan to pay for the refraction procedure. You say that you need this exam every year. The Plan 
denied your request. The Plan says refraction is not covered by Medicare or the Plan. 
 
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 routine vision exams but does not cover refractive procedures. 
 
We looked at the file and the Plan's rules. Refractive procedures are not covered even when done in connection 
with a covered diagnosis. Based on this information, we decided that the Plan's rules for coverage of the 
refraction procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction procedure provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says long term care is recommended. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there were no skilled nursing needs. As 
of 11/2/20, you did not require any skilled nursing or rehab services on a daily basis. You were not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. You did not require these services to establish a safe and effective 
maintenance program. As a practical matter, you did not require these services on an inpatient basis at a SNF 
level of 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says a group two power wheelchair is more appropriate due to fall history. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. A wheelchair 
would be more appropriate, per the documentation from the DME consultation. This is due to your fall history, 
and your home being unable to accommodate the turning radius of a scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from October 1, 2019 to 
October 10, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed 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 the inpatient services billed are not supported in the medical record. Specifically, the inpatient 
services were billed with 10 days. However, the services were provided for 9 days as the discharge day is not 
counted. Based on this information, we decided that Medicare rules for coverage of the inpatient services have 
not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from 
October 1, 2019 to October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) from DME purchased January 26, 2020. 
 
You asked the Plan to pay for sales tax. You say that the records provided should support the necessity of the 
service in dispute. The Plan denied your request. The Plan says sales tax is excluded and not covered under 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Code S9999 for sales tax is not payable as they are included in the cost of DME. Sales taxes where appropriate 
were included in the calculation of reasonable charges computed. They were also accounted for in the 
calculation of the base fee schedules for DME and orthotic/prosthetic devices. The Consumer Price Index used 
to update fee schedules also accounts for sales tax. Therefore, MACs do not make any additional payment for 
sales taxes and do not make adjustments in fees to reflect local changes in tax rates. We looked at the file and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of sales tax have not 
been met. Therefore, we decided that the Plan does not have to pay for sales tax (S9999) from DME purchased 
January 26, 2020.