Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108) for 
the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these are convenience items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested items are not medical in nature and therefore not 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (K0108) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on September 
2, 2020. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you needed the partial denture 
because you had to have a tooth pulled. The Plan denied your request. The Plan says this service is not a 
covered benefit 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 
maxillary partial denture (D5211) provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the medical eye exam (92004) and refraction 
services (92015) provided on September 18, 2020. 
 
You asked the Plan to waive the cost share for the medical eye exam and refraction services. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the 
cost share processed correctly in this case. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed as part of a routine vision exam. 
 
We looked at the file and the Plan's rules. In this case, you received eye refraction services as part of a medical 
exam which is not covered under your supplemental benefit. You have been charged a $20 copayment for the 
medical eye exam based on the contract. The eye refraction services are not covered. Based on this 
information, we decided that the Plan's rules for coverage of the refraction services has processed correctly and 
no reimbursement is due. Therefore, we decided that the Plan does not have to waive the cost share for the 
medical eye exam (92004) and refraction services (92015) provided on September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided June 5, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service is not separately 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 93010 is not supported in the medical record. Specifically, CMS does not separately 
pay any provider or supplier other than the facility for services furnished to the beneficiary for surgery. The 
facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and outside vendors. Payment for these services provided during surgery were 
included in payment to the facility. Based on this information, we decided that Medicare rules for coverage of 
the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (93010) provided June 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided June 26, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services are not separately 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 93010 is not supported in the medical record. Specifically, payment for this service was 
provided in payment to the facility that performed the surgery. This service is not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided June 26, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 8, 2020. 
 
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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
include definitive laboratory results for 22 or more drug classes. 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 G0483 provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on August 4, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glycosylated hemoglobin testing provided on April 27, 
2020. 
 
You asked the Plan to pay for the glycosylated hemoglobin testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the rendered services 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 test at issue in this appeal, the glycosylated hemoglobin testing, 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 glycosylated hemoglobin testing provided on April 27, 2020.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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. Our 
physician reviewer found the enrollee was admitted to the hospital with congestive heart failure. The enrollee's 
medical conditions are stable. The documentation does not support that the enrollee requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
the enrollee requires an intensive rehabilitation program. The enrollee's care needs can be met at 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urogynecology visits (99203, 99204) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the urogynecology visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not emergent and there are in-network providers 
who can render the services at issue. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve 
urogynecology visits (99203, 99204) 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 ambulance transportation provided on June 5, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that you contacted the Plan regarding transport and 
were told it was a covered expense. The Plan denied your request. The Plan says the denial of additional 
payment for this service is correct, because this was not the nearest appropriate facility so the Plan will pay for 
transportation costs that correspond to what would have been the nearest appropriate skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements, including from any point of origin to the nearest hospital 
or skilled nursing facility (SNF) capable of furnishing appropriate care.  
 
The services you have asked the Plan to pay for are ambulance transport services to a skilled nursing facility 
(SNF) that was not the nearest SNF capable of furnishing appropriate care to you. This means that the 
ambulance transport services do not meet Medicare?s coverage criteria. However, the Plan has agreed to 
reimburse you based on transportation costs that correspond to what would have been the nearest appropriate 
SNF. Therefore, we decided that the Plan does not have to pay for ambulance transportation provided on June 
5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. The Plan denied your request. The Plan says this drug is not 
covered for your condition by Medicare Part B. 
 
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 pre-approve Ubrelvy.  
 
Benefits for Ubrelvy 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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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. Our 
physician reviewer found the enrollee was admitted to the hospital for osteomyelitis of the left ankle. The 
enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not 
support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be 
met at 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (CPT 99358) provided to the enrollee on 
June 17, 2020. 
 
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 the documentation provided does not show how much time was spent performing non-face-to-
face services. 
 
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 99358 is "Prolonged evaluation and management service 
before and/or after direct patient care; first hour." 
 
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 
documentation indicates that 120 minutes were spent, including face to face time with the enrollee. CPT 99358 
is not reported if less than thirty minutes were spent. The documentation does not indicate the time spent face 
to face, or the additional time before and/or after face-to-face time. Therefore, the denied code cannot be 
verified. 
 
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 physician services (CPT 99358) provided to the enrollee on June 17, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve RUXIENCE, Cytarabine, BENDEKA, and Aloxi. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 medically necessary. Our physician reviewer found the enrollee has stage IV mantle cell 
lymphoma and is an autologous transplant candidate. Per the National Comprehensive Cancer Network 
(NCCN) guidelines, the requested regimen of R-BAC (rituximab, bendamustine and cytarabine) is the standard 
of care. The services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve RUXIENCE, Cytarabine, BENDEKA, and Aloxi.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to make payment at the ground ambulance rate for the air ambulance services 
(A0431, A0436) provided on July 7, 2020. 
 
You asked the Plan to make payment at the ground ambulance rate for the air ambulance services.. You say 
that you would like reconsideration because this service is payable at the ground ambulance rate. The Plan 
denied your request. The Plan says that air ambulance services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if air ambulance services were ordered, but 
ground ambulance transport would have sufficed, payment for the transport is based on the amount payable for 
ground ambulance transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air ambulance services. have been met. Specifically, you are requesting payment at the ground 
ambulance rate. This is a covered benefit per Medicare. Therefore, we decided that the Plan has to make 
payment at the ground ambulance rate for the air ambulance services (A0431, A0436) provided on July 7, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 3, 2020, to June 4, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider had opted 
out of Medicare. The Plan denied your request. The Plan says there is no referral on file for the specialist 
services. 
 
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 
services only when you receive a referral from your contract dentist and when the service is preauthorized in 
writing by the Plan?s dental vendor.  
 
We looked at the file and Medicare rules. The file indicates that although you may have received a referral 
from your dentist, the Plan?s dental vendor did not preauthorize the services in question. Based on this 
information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, 
we decided that the Plan does not have to pay for the dental services provided on June 3, 2020, to June 4, 2020, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the visual field exam and ophthalmic 
ultrasound provided on December 26, 2019. 
 
You asked the Plan to waive the copayments for the visual field exam and ophthalmic ultrasound. You say that 
you thought it would be one charge for both appointments. You say that you need help with the bill. The Plan 
denied your request. The Plan says the copayments 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 $20 per 
day for Medicare covered outpatient diagnostic tests and a $325 copayment per day for Medicare-covered 
diagnostic radiology services.  
 
You have been asked to pay a total of $33.42 for the visual field exam and ophthalmic ultrasound.  
 
Service Allowed Amount Standard Copayment Member Liability 
Visual Field Exam $74.19 $20 $20 
Ophthalmic Ultrasound $13.42 $325 $13.42 
TOTAL:   $33.42 
 
The visual field exam and ophthalmic ultrasound 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 copayments for the visual 
field exam and ophthalmic ultrasound provided on December 26, 2019.