Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the magnetic resonance angiography (MRA) of the 
head provided on October 8, 2020. 
 
You asked the Plan to pay for the MRA interpretation. You say that this was denied as duplicate in error. The 
records support that payment is due. The Plan denied your request. The Plan says that since these two codes are 
a PTP edit pair, the Column 2 code cannot be paid since no modifier was reported. 
 
The Plan must follow Medicare rules. Medicare rules say that NCCI PTP edits are based on services provided 
by the same physician to the same beneficiary on the same date of service. 
 
In this case, the Column 1 code referenced by the Plan was billed by a different physician than the code at issue 
in this case. As such, no modifier is required. The record clearly documents that this provider performed the 
services reported on this claim. We find that the denial of payment is not supported. Therefore, we decided that 
the Plan has to pay for the interpretation of the magnetic resonance angiography (MRA) of the head provided 
on October 8, 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 pre-approve the periodic oral evaluation (D0120) and adult dental 
cleaning (D1110). 
 
You asked the Plan to pre-approve the periodic oral evaluation and adult dental cleaning. You say that these 
services are necessary. The Plan denied your request. The Plan says you have exhausted your benefit for the 
services requested. 
 
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 periodic 
oral evaluation and adult dental cleaning once every six months. 
 
We looked at the file and Medicare rules. The file indicates that you last received these services in December 
2020. Therefore, these services have been exhausted until June 2021. Based on this information, we decided 
that the Plan's rules for coverage of the periodic oral evaluation and adult dental cleaning have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the periodic oral evaluation (D0120) and 
adult dental cleaning (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anesthesia services (01991) provided July 27, 2020. 
 
You asked the Plan to pay for the Anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Anesthesia services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 01991 is not supported in the medical record. Specifically, the primary procedure, a 
genicular nerve block was determined to be non-covered. Since the primary procedure did not meet Medicare 
coverage criteria, the associated services are also non-covered. Based on this information, we decided that 
Medicare rules for coverage of the Anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for Anesthesia services (01991) provided July 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE 
Ambulance on April 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by THE 
Ambulance on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 21, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician?s services. 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 physician's services provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 12, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that the facility did not obtain proper 
authorization but you ask that the Plan not penalize the doctor. The Plan denied your request. The Plan says 
you did not request 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 the physician services provided on May 12, 2020 by an out of network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include oxygen supplementation, intravenous antibiotics, surveillance laboratory studies and therapy 
services. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 on August 24, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services (CPT 95999) provided to the enrollee on 
October 7, 2019. 
 
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 this code shouldn't be billed with an anesthesia practitioner. 
 
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 95999 is "unlisted neurological procedure." 
 
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 in the medical records. Our coding reviewer found the services 
were billed with an appropriate code, per coding rules. 
 
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 medical services (CPT 95999) provided to the enrollee on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient post-stabilization services provided on April 24, 
2020 at 5:27 pm, through April 25, 2020. 
 
You asked the Plan to pay for inpatient post-stabilization services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized 
by 5:27 pm on April 24, 2020 and subsequent care was post stabilization care, not approved in compliance with 
the health plan's authorization procedures. 
 
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 post-stabilization services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the patient was stable 
for transport by 5:27 pm on April 24, 2020. 
 
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 post-stabilization services have not been met. Specifically, the patient 
was stable for transport and prior authorization was not obtained to continue services at the out-of-network 
facility. Therefore, we decided that the Plan does not have to pay for inpatient post-stabilization services 
provided on April 24, 2020, at 5:27 pm, through April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on August 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 skilled nursing services provided on August 25, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HLA Class I typing identified with code 81372, HLA 
Class II typing identified with code 81376, MRI identified with code 74181, and CT scan identified with code 
74150. 
 
You asked the Plan to pre-approve HLA Class I typing, HLA Class II typing, MRI, and CT scan. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services were previously approved and performed for the enrollee. 
 
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 81372, 81376, 74181, and 71450 is not supported in the medical record. Specifically, 
the services requested to be provided by a different provider have already been approved and received by the 
enrollee. Based on this information, we decided that Medicare rules for coverage of HLA Class I typing, HLA 
Class II typing, MRI, and CT scan have not been met. Therefore, we decided that the Plan does not have to pre-
approve HLA Class I typing identified with code 81372, HLA Class II typing identified with code 81376, MRI 
identified with code 74181, and CT scan identified with code 74150.  
 
We note that the enrollee is requesting to receive the transplant services at a different location than previously 
approved by the plan. The plan has made note that the enrollee may receive the transplant services by the 
requested provider. The plan is not approving the services already received by the previous provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 1, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were referred to this provider by the plan. 
You say that you did not choose to see this provider, you were referred. You say that you were given a new 
referral in September 2020 but could not get in contact with that office. You also say that you were not given 
the names of other in network providers. The Plan denied your request. The Plan says the provider in this case 
is out of network. The Plan says that dental services that you receive out of network are not 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, dental services that you receive out of 
network are not among those covered under this benefit. The record shows that you were advised prior to 
receiving the service that the provider was out if network. Additionally, the record shows you were given in 
network providers who were available. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210) provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE Fire 
Department on May 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were hit by a truck on a bicycle and 
were treated in place by the medics. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by THE Fire Department on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the continued OON care. You say that you need to start chemotherapy as 
soon as possible and do not want to wait to start the process with another doctor. The Plan denied your request. 
The Plan says there are in-network providers who can provide the care needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continued OON care. Our reviewer 
says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee 
has metastatic prostate cancer is being treated with Lupron and bicalutamide. This is a standard treatment 
regimen and care could be easily transitioned to an in-network oncologist. Out-of-network oncology care is not 
reasonable or medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued OON care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued care with an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam filling (D2150) provided on September 15, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you feel that at least a portion of the cost should 
be covered. The Plan denied your request. The Plan says the amalgam filling is an excluded service. 
 
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 
amalgam filling (D2150) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement received on September 18, 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 this is not a covered benefit. 
 
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. Your diagnosis is left and right toe pain. 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. Therefore, we decided that the Plan does 
not have to pay for nail debridement received on September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care 
hospitals. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include nebulizer treatments, intravenous fluid, surveillance 
laboratory studies, wound care, wound vacuum care, and therapy services. The documentation does not support 
that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.