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

 
We decided that the Plan does not have to pay for the lab services provided on February 4, 2020. 
 
You asked the Plan to pay for the lab services. 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 requested CPT codes are not supported in the medical record. Specifically, the records do not 
support that the requested services were performed by blood sampling. The lab requisition shows that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health occupational therapy (OT) services to 
be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON home OT services. You say that the enrollee needs OT in the 
home in order to address her condition. The Plan denied your request. The Plan says there is no evidence that 
an OON home health agency is required in this case. There are at least two home health agencies in the 
network one of which was used in June 2020 according to claims history. With no network deficiency for home 
health care, the requested OON referral is not necessary. 
 
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 care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the home health occupational therapy (OT) services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One to be supplied by a pharmacy. 
 
You asked the Plan to pre-approve Synvisc-One. You say that you are not able to have surgery right now, so 
this is your only option for treatment. The Plan denied your request. The Plan says the denial of authorization 
for this drug is correct, because this drug is not covered by Medicare Part B when supplied to you by a 
pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Synvisc-One to be supplied by a pharmacy.  
 
Benefits for Synvisc-One 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's care can be provided in a less intensive setting. 
 
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 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. The enrollee's rehab needs can be safely met in an alternate, less 
intense setting. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second emergency room visit (99285) and 
electrocardiogram (93010) provided on March 3, 2020. 
 
You asked the Plan to pay for a second emergency room visit and electrocardiogram. You say that this is 
supported in the records. The Plan denied your request. The Plan says only one visit is documented, which was 
previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT codes 99285 and 93010 are not supported in the medical record. The 
medical record only supports one unit of CPT codes 99285 and 93010, which were paid on a previous claim. 
Based on this information, we decided that Medicare rules for coverage of a second emergency room visit and 
electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for a second 
emergency room visit (99285) and electrocardiogram (93010) provided on March 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee underwent a pre-operative 
evaluation on October 14, 2020 prior to inguinal hernia repair. There were no documented cardiac symptoms, 
no documented cardiac physical exam abnormalities and no documented electrocardiographic abnormalities. In 
this circumstance, the documentation does not support that the TTE is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transthoracic echocardiogram (TTE) with Doppler.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 28, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you are aware of the frequency limit of the 
service you received. You also say that you have not received this service since April 2020. The Plan denied 
your request. The Plan says limited oral exams are covered once per plan year. The Plan also says that the 
frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral exams are a covered 
service, the frequency limit has been exceeded. The record shows the Plan paid for a limited oral exam that you 
received on May 16, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on May 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided to the enrollee on February 
7, 2020. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 pay for self-administered drugs provided 
to the enrollee on February 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stretcher van transportation services. 
 
You asked the Plan to pre-approve the stretcher van transportation services. You say that the enrollee is non-
weight bearing and cannot be put into a wheelchair at this time. You say that the enrollee is unable to be 
pivoted or transferred at all to a wheelchair. You say that the enrollee is completely confined to a bed. You say 
that the hospital would like to discharge your mother to a rehab facility so that she can work toward being 
transferred to a wheelchair. The Plan denied your request. The Plan says the services being requested are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for stretcher van transport 
services.  
 
The services you have asked the Plan to pre-approve are stretcher van transport services. Therefore, we decided 
that the Plan does not have to pre-approve stretcher van transportation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(99239) provided February 21, 2020. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that this claim denied 
incorrectly. This is a physician claim. There must be a facility claim on file. Kindly review the attached 
medical records and reconsider this claim for payment. The Plan denied your request. The Plan says only one 
hospital discharge day management service is payable per patient per hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that CMS does not pay 
any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital 
must furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers.  
 
In this case, CPT code 99239 was billed for February 21, 2020 by another provider and was processed for 
payment. Per the above Medicare guidelines, only one hospital discharge day management service is payable 
per patient per hospital stay. Only the attending physician of record reports the discharge day management 
service. Physicians or qualified non-physician practitioners, other than the attending physician, who have been 
managing concurrent health care problems not primarily managed by the attending physician, and who are not 
acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 - 
99233) for a final visit. Medicare pays for the paperwork of patient discharge day management through the pre- 
and post- service work of an E/M service. Based on this information, we decided that Medicare rules for 
coverage of the hospital discharge day management services have not been met. Therefore, we decided that the 
Plan does not have to pay for hospital discharge day management; more than 30 minutes (99239) provided 
February 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that you believe that this surgery is proven 
and should be covered. The Plan denied your request. The Plan says there is a lack of medical literature 
supporting this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve the sleep study. You say that the records provided support the need for the 
requested sleep study. The Plan denied your request. The Plan says there is no report of excessive sleepiness. 
The Plan says that there are no reports of stopping breathing or of trouble sleeping. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient is a 64-year-old female who is diagnosed with sleep apnea, obesity, hypertension, 
who noted jaw discomfort from her oral appliance. A request for a sleep study was made. There was no 
explanation as to why the patient could not adjust the oral appliance as part of an outpatient office visit vs a 
sleep study. Repeating a sleep study was also not justified by any other indication for such. The patient did not 
reveal or describe shortness of breath, excessive sleepiness, fatigue, awakening/gasping/choking to justify 
repeat sleep study 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 the sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder arthroscopy with distal claviculectomy, 
decompression of the subacromial space and rotator cuff repair. 
 
You asked the Plan to pre-approve the shoulder surgery. You say that the findings of the imaging and physical 
exam support the need for this surgery at this time. The Plan denied your request. The Plan says there must be a 
trial of conservative therapy before surgery can be approved regardless of whether the condition is due to 
traumatic injury. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the shoulder surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of adequate conservative care to include physical therapy for 
shoulder pain. Without failure of therapy, criteria for surgery are not 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 the shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the shoulder arthroscopy with distal claviculectomy, decompression of the 
subacromial space and rotator cuff repair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ambulance trip provided a participating 
provider on February 3, 2020. 
 
You asked the Plan to waive the coinsurance for an ambulance trip. You say that you do not know why this is 
being denied. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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 5% 
coinsurance for ambulance services.  
 
You have been asked to pay a 5% coinsurance of the allowed amount for an ambulance trip. The total allowed 
amount is $420.08 x 5% = $21.00). These services were not denied. An ambulance trip falls within the 
ambulance 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 coinsurance for an ambulance trip 
provided \on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you want to see the provider because of the 
treatment he gives. The Plan denied your request. The Plan says the requested service is available within your 
health plan network. 
 
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 care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurology services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services provided on May 5, 
2020. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergent ambulance services provided on May 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to recoup payment for the prophylaxis (D1110) provided on July 14, 
2020. 
 
You asked the Plan to recoup payment for the dental service. You say that this service should not be paid. You 
say that you are not satisfied with the service that you received. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service you received was processed 
correctly. Therefore, we decided that the Plan does not have to recoup payment for the prophylaxis (D1110) 
provided on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0481 provided on 
October 11, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80307 and G0481 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician stating exactly what tests were to be performed. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded 80307 and G0481 provided on October 11, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit 
(99215,99490) provided from May 12, 2020, to June 30, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 established patient office or other outpatient 
visit (99215,99490) provided from May 12, 2020, to June 30, 2020, by an out-of-network (OON) provider.