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

We decided that the Plan does not have to pay for the bevacizumab injection rendered on January 16, 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 J9035 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J9035 is injection, bevacizumab, 10 mg. 
 
We find that CPT code J9035 is not supported in the medical record. Specifically, the documentation does not 
identify the amount of drug wasted. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the bevacizumab 
injection rendered on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 22, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the claim was not billed with the required durable medical 
equipment modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate modifier. 
 
We find that the claim was not submitted correctly. Specifically, the CR modifier is missing. The codes 
classified as Category 'CR' have to be billed with the correct modifier and only permitted to be reimbursed for 
rental only. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided 
on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan 
denied your request. The Plan says a decision has not been made in the required time frame. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
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 dental service. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation submitted does 
not support the need for a crown for tooth #30. The reviewer found there does not appear to be significant 
coronal breakdown. Therefore, the reviewer found that the crown is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth #30.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a more appropriate test would be an ankle-brachial artery index or arterial duplex. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
studies in question. There is no documentation provided of enrollee complaints. There is no documentation 
provided of a physical examination. There is no documentation of abnormal ABIs. Therefore, the procedures in 
question cannot be considered 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a duplex scan for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on May 28, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were told that tests would need 
to be ran again and then left. The Plan denied your request. The Plan says the copayment was 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 $90 
copayment for Medicare-covered emergency room visits.  
 
Review of the file shows that you received ER services on May 28, 2020. Per the contract with the Plan, there 
is a $90 copayment for Medicare-covered emergency room visits. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services 
was $67.47. Given that the allowed amount was less than the $90 copayment, you have been asked ot pay 
$67.46 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) 
services rendered on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided from April 7, 2018, to 
April 12, 2018. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you do not believe the circumstances 
justify the Plan's decision to deny payment. The Plan denied your request. The Plan says the time limit for 
filing the claim had expired. 
 
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 inpatient hospital stay was not filed until January 7, 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 inpatient hospital stay provided from April 7, 2018, to April 
12, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling for tooth # 24 (D2332) and the filling for tooth # 8 
(D2330) provided on August 5, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
you had dental coverage. You say that the plan representative did not advise that only 2 fillings would be 
covered per calendar year. You say that the plan should pay at least half of your bill. You also say that you 
cannot afford to pay this bill as you are on a fixed income. The Plan denied your request. The Plan says 2 
fillings per calendar year are covered. 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, the frequency limit for fillings has 
been exceeded. The record shows that the Plan paid for 2 fillings that you received on January 15, 2020. 
Therefore, we decided that the Plan does not have to pay for the filling for tooth # 24 (D2332) and the filling 
for tooth # 8 (D2330) provided on August 5, 2020.  
 
Your complaint about being misinformed by a plan representative 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided May 25, 2020. 
 
You asked the Plan to pay for the critical care services. You say that please review supporting documentation 
and reprocess the claim for payment. The Plan denied your request. The Plan says duplicate of previously paid 
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 billing of code 99291 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another provider. This code can only be billed 
once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) provided May 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. 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. The 
Plan says that these services could have been provided in-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 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 outpatient services provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair provided on April 28, 2020. 
 
You asked the Plan to pay for the standard wheelchair. You say that this equipment was provided to the 
enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says the 
enrollee received the wheelchair following surgery at the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital 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. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the 
home. Medicare does not consider a hospital to be a home. 
 
This equipment was used during inpatient hospitalization.  Payment for this wheelchair would have been 
included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. 
Therefore, we decided that the Plan does not have to pay for the standard wheelchair provided on April 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered experimental/investigational due to the wide variation in efficacy in the 
peer-reviewed literature. Therefore, the request is considered not medically reasonable or 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 sacral radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that your balance is still off. The Plan denied your 
request. The Plan says you do not require daily skilled nursing or therapy services on an inpatient basis. 
 
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 SNF services. Our physician reviewer 
found that from a nursing perspective, you had stable vital signs, your lungs were clear, and you had 
uncomplicated wound care to several sites. There are no identifiable skilled nursing service needs. Regarding 
rehab services, you were at a contact guard to independent assist level with functional mobility. You require 
varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you 
do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services rendered from July 2, 2019 to July 12, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the claim is not payable because the diagnosis is inconsistent 
with the procedure; however, the Plan has not provided any further explanation of the denial reason. There is 
no documentation of the services at issue to support that the billed diagnosis is inappropriate. The Plan has not 
provided any further Medicare rules to support that the services are not payable as billed. Therefore, we 
decided that the Plan has to pay for the inpatient hospital services rendered from July 2, 2019 to July 12, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found radiofrequency ablation of the lateral sacral branches is 
considered experimental because of the wide variation in efficacy reported in peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine podiatry services provided on July 
9, 2020. 
 
You asked the Plan to waive the copayment for routine podiatry services. You say that you disagree with the 
charges because you already paid a $45 copayment. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $20 
copayment for each routine podiatry visit.  
 
You have been asked to pay a $20 copayment for routine podiatry services. Routine podiatry services fall 
within the podiatry 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 copayment for routine 
podiatry services provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an intensive therapy 
program is not appropriate for your condition. 
 
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 physician reviewer found 
that you were admitted to the acute hospital congestive heart failure, and have ongoing weakness. Your 
medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record 
supports a need for physical and occupational therapy, but it does not support a need for an intensive 
rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two gingival irrigations (D4921 x2), fixed partial denture 
sectioning (D9120), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on 
August 7, 2020, and August 19, 2020. 
 
You asked the Plan to pay for the gingival irrigations, fixed partial denture sectioning, and drugs or 
medicaments. You say that you needed these services in preparation for hip surgery. The Plan denied your 
request. The Plan says these services are not covered benefits under your dental 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 pay for the two 
gingival irrigations (D4921 x2), fixed partial denture sectioning (D9120), and drugs or medicaments dispensed 
in the office for home use (D9630 x2) provided on August 7, 2020, and August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 16, 2020. 
 
You asked the Plan to pay for the laboratory 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 a covered benefit. 
 
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 laboratory testing at issue in this appeal 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 for the 
laboratory services provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical mattress. 
 
You asked the Plan to pre-approve the medical mattress. You say that you have spinal issues and arthritis and 
believe a medical grade mattress would be helpful for you. The Plan denied your request. The Plan says this is 
not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Although it may be helpful for people with certain medical conditions, a mattress, regardless of its grade or 
features, is not considered to be primarily medical in nature. This is considered furniture and is available to the 
general public, and not only to those who are sick or injured. Mattresses may be covered as accessories to a 
hospital bed; however, no request for a hospital bed was made in this case. Therefore, we decided that the Plan 
does not have to pre-approve a medical mattress.