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

We decided that the Plan does not have to pay for the laboratory services provided on January 27, 2020.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approved a Group 3 power mobility device (PMD) and accessories (E2300, E1007, K0861, E1012).
You asked the Plan to pre-approved the Group 3 PMD and Accessories. You say that this chair is medically necessary. The Plan denied your request. The Plan says a power chair was provided in 2017 that should continue to meet the needs of the enrollee.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approved a Group 3 power mobility device (PMD) and accessories (E2300, E1007, K0861, E1012).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you have had 
all of your teeth removed and need dentures. The Plan denied your request. The Plan says these services are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture and a complete mandibular denture.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on December 
4, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that your ambulance 
transportation should be covered under the emergency room copayment. You should not have a separate 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance Services benefit category. The record shows that Worldwide coverage for emergency services 
refers to services received outside of the United States.  
 
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 ambulance ride provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493).
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's pain is not localized to the neck or back.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered only when all of the indications listed above are met. 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 facet joint injections. Our reviewer says that the requested injections are not medically necessary at this time. Our physician reviewer found the provided medical records do not document that the enrollee has had at least 3 months of moderate to severe pain with functional impairment inadequately responsive to conservative care, predominant axial pain that is not associated with radiculopathy or neurogenic claudication, an absence of non-facet pathology, and a clinical assessment that implicates the facet joint as the putative source of pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and a bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that a 
bone defect at tooth #9 compromised tooth #'s 8 and 10. You also say that tooth #'s 8 and 10 will be lost if the 
defect is not corrected. The Plan denied your request. The Plan says these services are not covered under the 
enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a 
guided tissue regeneration (D4266) and a bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301).
You asked the Plan to pre-approve a power seat elevation feature and power standing feature. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The requested items are not covered under Medicare. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature and power standing feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health medial social worker services. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says in the notes from the one approved social worker visit, it states that no additional visits 
are needed. 
 
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. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you do not require 
home health social work services to effectively provide treatment, care, and/or services in order to improve 
your condition, or to maintain your condition and/or prevent deterioration. You received information on in 
home support services, transportation and the documentation does not reveal that social worker services are 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health medial social worker services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on February 28, 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 procedure code 73562 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 73562 and 77073. Code 73562 is a column II code with a 
modifier indicator of 1 when billed with column I code 77073. Code 73562 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the knee 
x-ray rendered on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services (99499 x 30) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that it is medically necessary that the enrollee 
remain under your medical care, as he is currently undergoing intense work-up and treatment of chronic pain, 
and diabetes and cholesterol management. The Plan denied your request. The Plan says the requested services 
are not medically necessary with an out of network provider. There are available providers within the Plan's 
network who can treat the enrollee. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 these services. Our reviewer says that the request for continued care with an 
out of network provider is not medically necessary. Our physician reviewer found that the enrollee has a past 
medical history of diabetes, renal insufficiency and hyperlipidemia who is undergoing evaluation and treatment 
for chronic pain as well as diabetes and hyperlipidemia with an out of network provider. Based on the medical 
records provided, there is no documentation that indicates continued care with the out of network provider is 
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 these services have not been met.  
 
 
 
 
The Plan has network providers available who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does 
not have to pre-approve evaluation and management services (99499 x 30) to be provided by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve therapeutic parenteral drugs (D9612). You say that most of your teeth are 
broken and its hurting a lot. You say that you really need this procedure. The Plan denied your request. The 
Plan says the service 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 therapeutic parenteral drugs are not 
among those covered under this benefit. Please note, the records show that the extractions and deep sedation 
were pre- approved. Therefore, we decided that the Plan does not have to pre-approve therapeutic parenteral 
drugs (D9612).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from 
October 15, 2019 to January 7, 2020. 
 
You asked the Plan to pay for the home infusion therapy services (S9328). 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. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  
 
We looked at the file, Medicare rules, and the Plan's rules. Based on this information, we decided that 
Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home infusion therapy services (S9328) provided from October 15, 
2019 to January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided to the enrollee on 
November 12, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is a duplicate of a charge considered on a previous claim. 
 
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 the denied codes is: 
 
CPT 88305: 
 
Surgical pathology, gross and microscopic examination 
 
CPT 88342: 
 
Immunohistochemistry or immunocytochemistry, per specimen 
 
CPT 88360: 
 
Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), 
quantitative or semiquantitative, each antibody  
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the records 
submitted display the following for claim #820193470231714: CPT 88305-26 1 unit, CPT 88342 26 59 1 units 
and CPT 88360-26 2 units. The Check Remittance Advice attached is dated January 2, 2020 and these codes 
were paid. Therefore, these same codes submitted to the health plan for date of service November 12, 2019, 
claim # 820200150141848 does not meet the criteria for reimbursement as they have already been paid. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical pathology services provided to the enrollee on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a pressure-reducing air mattress. You say that you need this because you 
have a pressure ulcer. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that group 2 support surfaces such as pressure-
reducing air mattresses are covered for enrollees who have ulcers located on the trunk or pelvis as described 
above. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that you have ulcers 
located on the trunk or pelvis. Based on this information, we decided that Medicare rules for coverage of a 
pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pressure-reducing air mattress (E0277).
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 enrollee needs close monitoring, 
daily physician visits, and intensive complex skilled services that are too frequent and needed beyond what can 
be managed in a lower level of care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the services needed could be provided in another setting. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with 2-day history of blood-tinged sputum and left pleuritic 
chest pain. She was diagnosed with pneumonia and treated with antibiotics and COPD exacerbation 
medications. She had volume overload requiring hemodialysis. She was treated with BiPAP and oxygen. 
Currently she is still requiring 6L oxygen, steroid taper, hemodialysis, steroids, and nebulizers with very slow 
recovery. She is being followed by palliative care due to her poor prognosis. The enrollee does not require 
services at the proposed LTACH that are not already available at the current acute care hospital. There are no 
unique services available at the proposed LTACH that the enrollee requires that are not already available and 
covered in the current facility. The enrollee requires ongoing acute care services currently, however, 
considering the gradual improvement thus far, it is not clear that she will need more than an additional 25 days 
of acute care before being able to transfer to a lower 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair ramp, home modifications (S5165) 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that you need the wheelchair ramp approved 
to go outside of the apartment. The current wheelchair ramp is rotted out and the wood is deteriorated with big 
holes and is not safe to use. The Plan denied your request. The Plan says this item is not covered. 
 
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 the wheelchair ramp, home modifications (S5165)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the physician services provided on March 17, 2020.
You asked the Plan to waive the cost share for the physician services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received specialist services on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $100 deductible for Physician/Practitioners services and a $25 copayment for specialist visits once the deductible has been met. The item or service you asked the Plan to waive the cost share for falls within the benefit category Physician/Practitioners services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 deductible for Physician/Practitioners services. This cost sharing is a contractual obligation that had not been met at the time the physician services were received on March 17, 2020. You have now met your deductible, which now applies a $25 copayment for the specialist visit. Therefore, we decided that the Plan does not have to waive the cost share for the physician services provided on March 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on April 10, 
2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the claim was denied because of an invalid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be coded and reported 
correctly. 
 
A corrected claim is needed for this case, as an incorrect HIPPS code was used. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided to the enrollee on April 10, 2020.