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

We decided that the Plan does not have to pay for the orthoses provided on April 10, 2020. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the medical records do 
not support the need for the items. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The documentation shows that the enrollee received a cervical orthosis, and an ankle-foot orthosis. 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 orthoses. Our physician reviewer found that it is 
documented that the enrollee has right foot pain due to a bullet lodged in the ankle/foot region. He has not had 
surgery yet. The enrollee's neck and back pain had worsened over the previous few months, as he was out of 
his medications. The documentation in the case file does not support that the requested ankle/foot orthoses 
were medically reasonable and necessary for the enrollee 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the orthoses provided on April 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health physical therapist services provided on June 
20, 2020. 
 
You asked the Plan to pay for services performed by a qualified physical therapist assistant in the home health 
or hospice setting, each 15 minutes (G0157). You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says the Medicare enrollment approval letter received from the Medicare Appeals Council 
(MAC) certifies the NPI billed for this claim is enrolled in the Medicare program as a physician group and 
must bill on a CMS 1500 form. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The requirements for payment identified in the approval letter have not been met as the wrong claim form was 
used. The UB-04 (CMS 1450) is a claim form used by hospitals, nursing facilities, in-patient, and other facility 
providers. Based on this information, we decided that Medicare rules for coverage of services performed by a 
qualified physical therapist assistant in the home health or hospice setting, each 15 minutes (G0157) have not 
been met.  
 
Therefore, we decided that the Plan does not have to pay for the home health physical therapist services 
provided on June 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional component of the EKG provided on March 
2, 2020. 
 
You asked the Plan to pay for the Electrocardiogram, routine ECG with at least 12 leads; interpretation and 
report only (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 
there is no documentation of an interpretation by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the professional component of a diagnostic procedure 
furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary's 
medical record maintained by the hospital. 
 
We looked at the file and Medicare rules. There is no interpretation and written report of the EKG in the file from 
the physician on the claim form. Based on this information, we decided that Medicare rules for coverage of the 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010) have not been met. 
Therefore, we decided that the Plan does not have to pay for the professional component of the EKG provided 
on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from November 4, 2019 to 
November 5, 2019. 
 
You asked the Plan to pay for inpatient care. You say that you are appealing based on medical necessity. The 
Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because this was 
post-stabilization care and approval was not obtained from the Plan.  
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that this 
inpatient hospital care does not meet the Medicare criteria for coverage. Our physician reviewer found the 
enrollee was stable for transfer to an in-network facility without any likely deterioration of the enrollee. Post-
stabilization care was not authorized so the Plan has no obligation to pay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital care provided from November 4, 2019 to November 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 2, 2020 to 
July 7, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that you are requesting an appeal for the 
denial of this claim. The Plan denied your request. The Plan says the documentation does not support the need 
for a skilled nursing level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from July 2, 2020 to July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
on June 26, 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 prosthodontic services are excluded from 
coverage. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for mandibular partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 30 & 31. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
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 crowns 
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 crowns. Our reviewer says that the 
crowns do not meet coverage criteria. Our physician reviewer found the provided documentation reveals that 
both teeth had prior restorations, a one surface amalgam on #31 and a two surface amalgam on #30.  The 
amount of damaged tooth structure on either tooth does not appear to exceed 40%, and there does not appear to 
be any involvement of the cusps. Our reviewer found that the provided photos are not marked with a tooth 
number, but stains along grooves are seen on one photo. The presence of stains along groves does not indicate a 
risk of imminent fracture of a tooth, and is not indicative a need to place a crown on a tooth exhibiting these 
stained craze lines. Our physician reviewer also found that the amount of damage to either tooth is insufficient 
to rise to the level of necessity for a crown restoration, and a conventional restoration would be appropriate.  
There is no medical necessity for the requested crowns in this instance. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #'s 30 & 31.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services from July 23, 2019 through August 1, 
2019 provided by a non-Medicare provider. 
 
You asked the Plan to pay for home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says because the services were submitted on a UB-04 and the provider is not a Medicare 
certified facility, the requirements for payment identified in the Medicare certification letter have not been met. 
 
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 home health services have not been met. No provider or supplier 
shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is 
enrolled in the Medicare program.  Further, it is essential that each provider and supplier enroll with the 
appropriate Medicare fee-for-service contractor. The letter received from the Medicare Appeals Council 
(MAC) certifies the NPI billed for this claim is enrolled in the Medicare program as a physician group and 
must bill on a CMS 1500 form. Because the services were submitted on a UB-04 and the provider is not a 
Medicare certified facility, the requirements for payment identified in the Medicare certification letter have not 
been met and the initial determination is upheld. Therefore, we decided that the Plan does not have to pay for 
home health services from July 23, 2019 through August 1, 2019 provided by a non-Medicare provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided 
from November 19, 2019 to November 25, 2019. 
 
You asked the Plan to pay for the home infusion therapy 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. 
 
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 S9502 is home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9502 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9502 provided from November 19, 2019 to 
November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2752) for tooth #28. 
 
You asked the Plan to pre-approve the crown. You say that you sent x-rays several times, including digital x-
rays. The Plan denied your request. The Plan says that the required x-rays were not provided to support the 
procedure. 
 
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 crown 
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 crown. Our reviewer says that the 
crown is medically necessary. Our physician reviewer found the documentation submitted meets the criteria for 
coverage for a crown restoration (D2752) for tooth #28. 
 
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 crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2752) for tooth #28.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
November 25, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing has not been billed 
with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service November 25, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various medical services received on December 31, 2019. 
 
You asked the Plan to pay for the services. You say that you were not advised that you had to make an 
appointment with your PCP to ask for a referral. The Plan denied your request. The Plan says the services 
received were not authorized and not payable by the plan. 
 
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 various medical services received on December 
31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two abutment supported porcelain/ceramic crowns 
(D6058 x2) and custom fabricated abutment (D6057) provided on May 18, 2020. 
 
You asked the Plan to pay for the abutment supported porcelain/ceramic crowns and custom fabricated 
abutment. You say that the bridge was placed in order to achieve chewing stability. 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 
abutment supported porcelain/ceramic crowns (D6058 x2) and custom fabricated abutment (D6057) provided 
on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
April 2, 2020. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that you request processing the 
claim in-network since you are the only service provider for Guardant360. The Plan denied your request. The 
Plan says there is a more appropriate code to describe 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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, there is a more appropriate 
code to describe the services provided. Providers must not unbundle the services described by a HCPCS/CPT 
code. Based on this information, we decided that Medicare rules for coverage of unlisted molecular pathology 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular 
pathology procedure (81479) provided April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network services and the lab 
services were not ordered by a Plan contract provider. 
 
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 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 lab services provided to the enrollee on May 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the cost share charged for Medicare Part B drugs 
provided on April 14, 2020. 
 
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. 
The Plan denied your request. The Plan says  
 
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% 
coinsurance for Medicare Part B drugs such as injections. Based on your 2020 Plan contract agreement and the 
services provided, 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 or reduce the cost share charged for Medicare Part B drugs provided on 
April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent disease testing provided on September 23, 
2019. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct. 
 
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 laboratory testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was noted to have had a chronic leg wound. There is no documentation as to why a 
standard wound culture with sensitivity testing would not have been sufficient to diagnose or treat the enrollee. 
There is no documentation of why this testing was thought to be medically necessary to diagnose or treat the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for infectious agent disease testing provided on September 23, 2019.