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

 
We decided that the Plan does not have to reimburse for nonemergency transportation and air travel (private or 
commercial) provided on December 23, 2019, by a foreign provider. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says this service is not covered by Medicare and clearly 
excluded per your EOC. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Your EOC states, transportation back to the United States from 
another country is not covered. Therefore, we decided that the Plan does not have to reimburse for 
nonemergency transportation and air travel (private or commercial) provided on December 23, 2019, by a 
foreign provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on June 26, 2020, by an out-of-network 
provider. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says they did not received a primary care physician (PCP) referral to review and approve. The Plan 
states these services are not urgent or emergent. 
 
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 DME provided on June 26, 2020, by an out-of-
network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 1, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the corrected claim 
was submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until June 1, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that the dentures you currently 
have do not work properly, and keep falling. The Plan denied your request. The Plan says this service is 
allowed one time every 60 months. The Plan also says that you received this service less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture on December 5, 2016, and your 
maxillary dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CTA, chest (noncoronary), with contrast material(s), 
including noncontrast images, if performed, and image postprocessing (CPT Code 71275) and CTA, abdomen 
and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing 
(CPT Code 74174) provided on May 19, 2020. 
 
You asked the Plan to pay for the CTAs. You say that you provided records supporting separate services 
rendered. The Plan denied your request. The Plan says the services were previously approved/paid and this is a 
duplicate. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CTAs have not been met. The member had imaging studies on 
May 19, 2020. The submitted documentation supports 1 (one) unit each of 74174-26 and 71275-26, which were 
previously approved/paid. There is no additional documentation supporting additional studies which were 
billed and remain denied. This is a billing issue. Therefore, we decided that the Plan does not have to pay for 
CTA, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image 
postprocessing (CPT Code 71275) and CTA, abdomen and pelvis, with contrast material(s), including 
noncontrast images, if performed, and image postprocessing (CPT Code 74174) provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on May 27, 2020. 
 
You asked the Plan to pay for the Tdap vaccine. The Plan denied your request. The Plan says this is not 
covered under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the Tdap 
vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on May 
27, 2020.  
 
Benefits for the Tdap vaccine 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 pre-approve a root canal (D3330) for tooth # 30. 
 
You asked the Plan to pre-approve a root canal for tooth # 30. You say that the enrollee needs the crown for 
tooth # 30. The Plan denied your request. The Plan says root canals are covered once per tooth per lifetime. The 
Plan says that the frequency limit has been reached. 
 
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 root canal is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal 
(D3330) for tooth # 30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail trimming service (G0127) provided on July 6, 2020, by a 
non-Plan provider. 
 
You asked the Plan to pay for the services. You say that the member is incapacitated and in a memory care 
facility. You state the staff is not skilled to cut toenails and the member cannot leave the facility to have a plan 
provider perform the service and will not allow family to come in and cut the toenails due to COVID. The Plan 
denied your request. The Plan says the member does not have diabetes and the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. The member does not have diabetes and the services are not covered. The EOC 
states that routine care is only covered under specific conditions: Unless you meet the qualification under 
Original Medicare for diabetic foot care, there is no coverage for any routine foot care, regardless of care 
setting, including but not limited to toenail trimming, nail debridement, and/or callous or corn treatment.  
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for nail trimming service (G0127) provided on July 6, 
2020, by a non-Plan provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical, semi-rigid, adjustable molded chin cup (plastic 
collar with mandibular/occipital piece) (CPT Code L0150) provided on July 24, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the DME was not filed until July 31, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for cervical, semi-rigid, adjustable molded chin cup (plastic collar with 
mandibular/occipital piece) (CPT Code L0150) provided on July 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 85060) provided on June 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 85060 is not supported in the medical record. Specifically, CPT code 85060 was billed 
with outpatient POS code 22. No payment is recognized for code 85060 furnished to hospital outpatients or 
non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment 
for the clinical laboratory test. 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 the services (CPT 
85060) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT Code 
E0745) provided on May 9, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied 
your request. The Plan says there are no clinical notes from the member's primary health provider. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation of a physical exam. Coverage of Neuromuscular Electrical 
Stimulation to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the 
muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for 
disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft 
tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). The documentation does 
not support that the coverage criteria have been met in this case.  
 
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 pay for neuromuscular stimulator, electronic shock unit (CPT Code E0745) provided on May 9, 2020, 
by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) with doppler 
complete (93306). 
 
You asked the Plan to pre-approve a TTE with doppler complete. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 a TTE with doppler complete. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance the records do not support the medical necessity for a 
repeat echocardiogram less than 2 months from the prior exam. Current guidelines also do not consider a repeat 
echocardiogram appropriate in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE with doppler complete have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transthoracic echocardiography (TTE) with doppler complete (93306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two (2) intraoral - periapical each additional radiographic 
image (D0230 x 2) provided on June 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says you exhausted your 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. 
 
Review of the file shows that you received three (3) sets of periapical x-rays performed on June 9, 2020. The 
Plan paid for D0220 and you are responsible for two (2) D0230. Your EOC states that you are allowed one (1) 
procedure (periapical x-rays) per calendar year. These procedures (D0220, D0230) have exceeded allowed 
EOC frequency limits and are therefore not covered benefits under your supplemental dental plan . Therefore, 
we decided that the Plan does not have to pay for two (2) intraoral - periapical each additional radiographic 
image (D0230 x 2) provided on June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the thyroid imaging and iodine provided on 
May 8, 2020. 
 
You asked the Plan to waive the cost share for the thyroid imaging and iodine. You say that you were advised 
there was a copayment of $30 for each procedure. You say that you should not owe any further money. The 
Plan denied your request. The Plan says the cost share applied 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 a $155 
copayment for each Medicare-covered radiological diagnostic service and 20% coinsurance for each Medicare-
covered medical supply. 
 
You have been asked to pay a total of $193.40 for the thyroid imaging and iodine.  
 
Service Allowed     Amount     Standard Cost     Member Liability 
Thyroid Imaging     $277.95     $155                   $155 
Iodine                   $192          20%                   $38.40 
TOTAL:   $193.40 
 
The thyroid imaging and iodine fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies" 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 cost share for the thyroid imaging and 
iodine provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the Otolaryngology services. You say that you would like reconsideration 
because the in-network provider cancelled your appointment and you trust the out-of-network provider. The 
Plan denied your request. The Plan says the services are not urgent or emergent. 
 
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist. 
 
You asked the Plan to pre-approve the referral. You say that you would like to continue care with this provider. 
The Plan denied your request. The Plan says participating providers are available. 
 
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 
a referral to an out-of-network dermatologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional subsequent 15 minute increment of 
intravenous moderate (conscious) sedation/analgesia. 
 
You asked the Plan to pre-approve the additional sedation/analgesia. You say that you do not agree with the 
denial of the additional 30 minutes of sedation for the dental procedure. The Plan denied your request. The Plan 
says only one subsequent 15 minute increment of sedation is 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, moderate sedation is limited to a 
maximum interval of 30 minutes. The record shows that you have been approved for the first 15 minutes of 
intravenous moderate (conscious) sedation/analgesia, and one subsequent 15 minute increment of intravenous 
moderate (conscious) sedation/analgesia, which is a total of 30 minutes, and exhausting your sedation benefit 
for the procedure. Therefore, we decided that the Plan does not have to pre-approve an additional subsequent 
15 minute increment of intravenous moderate (conscious) sedation/analgesia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99348) provided on August 12, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided. 
 
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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the record does not provide any 
evidence that the physician was present in the member's home. Based on this information, we decided that 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit (99348) provided on August 12, 2019.