Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures. 
 
You asked the Plan to pre-approve dentures. You say that you need dentures in order to eat. The Plan denied 
your request. The Plan says dentures are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve complete 
upper dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four applications of desensitizing medicaments (D9910 
x4). 
 
You asked the Plan to pre-approve the applications of desensitizing medicaments. The Plan denied your 
request. The Plan says this service is 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
applications of desensitizing medicaments (D9910 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick urine collection system and catheters 
(E1399). 
 
You asked the Plan to pre-approve a PureWick urine collection system and catheters. You say that this is 
necessary to prevent urinary tract infections. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that catheters are non-reusable disposable supplies 
and are therefore not covered. 
 
We looked at the file and Medicare rules. The requested items are not covered. Based on this information, we 
decided that Medicare rules for coverage of a PureWick urine collection system and catheters have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a PureWick urine collection system and 
catheters (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on February 3, 2020. 
 
You asked the Plan to pay for sedation services. You say that this is documented in the records. The Plan 
denied your request. The Plan says this code 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted medical 
records do not document the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for sedation services (99152) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Liletta IUD. 
 
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 not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that IUDs are not covered. 
 
The requested service is not covered by Medicare. 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 the insertion of a Liletta IUD.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 18, 2020.

You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was submitted with a sequela code as the primary.

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 the claim was not correctly billed. Specifically, S72.142S is listed as the primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on July 26, 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 procedure code 99350 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 99350 is Level 4 home visit for the evaluation and 
management of established patient with problem of moderate to high severity, including comprehensive 
interval history and medical decision making of moderate to high complexity, typical time with patient 60 
minutes. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the file shows that the 
services were not rendered by a physician, but by a registered nurse. 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 services rendered on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer with compressor rendered on March 30, 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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that modifier -NU must be billed for durable medical 
equipment that is new. 
 
We looked at the file and Medicare rules. The provider submitted procedure code E0570 with the NU modifier; 
however, the modifier is not appropriate, as the item is a capped rental item. 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 nebulizer with compressor rendered on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2020. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this provider is not recognized as payable by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. The rules say that below is 
a list of individuals and entities that frequently attempt to enroll in Medicare, but are not eligible to do so. If the 
contractor receives an enrollment application from any of these individuals or entities, the contractor shall deny 
the application, with the exception of entities eligible to enroll using the Form CMS-20134, which is specific to 
the furnishing of MDPP services. Therefore, a registered nurse is listed. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on April 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered from March 6, 2020 to 
March 11, 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 99291 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered from March 6, 2020 to March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture with interpretation (D0366), 
custom abutments (D6057) for teeth # 12 and 13, and bone grafts at the time of implant placements (D6104) 
for teeth # 12 and 13. 
 
You asked the Plan to pre-approve the dental services. You say that the original pre-authorization request was 
sent to Medicaid instead. You also say that the claim for dentures from a previous provider was false as the 
enrollee's top teeth are intact. The Plan denied your request. The Plan says the requested services are not listed 
as 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam CT capture with interpretation (D0366), custom abutments (D6057) for teeth # 12 and 13, and bone 
grafts at the time of implant placements (D6104) for teeth # 12 and 13.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health care provided to the enrollee from May 23, 
2020, through May 29, 2020. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the stay was medically 
necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital services. Our 
physician reviewer found based upon review the records provided it was expected this enrollee would improve 
in a reasonable period of time as they did not have dangerousness to self but did have dangerousness to others, 
auditory or visual hallucinations with response to internal stimuli. It did appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as he did not have dangerousness to self but did have homicidal thoughts to others, perceptual disturbance 
including auditory and visual hallucinations. The health plan's denial of inpatient psychiatric services appears 
inappropriate. This enrollee did appear to require inpatient mental health treatment as the enrollee was not a 
danger to themselves but others. It did appear that active treatment was taking place. It did appear that the 
services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. This 
enrollee was treated under an individualized treatment plan found in the record. It did appear that the records 
were supervised and evaluated by a physician. Based upon review the records provided, for the admission of 
this patient does meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to 
be a danger to themselves but is a danger to others with auditory or visual hallucinations in response the 
internal stimuli. 

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 psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient mental health care provided to the enrollee from May 23, 2020, through 
May 29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Insulin Lispro. 
 
You asked the Plan to pre-approve the Insulin Lispro. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug and 
not covered under 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 the Insulin Lispro.  
 
Benefits for the Insulin Lispro 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform (E0118). 
 
You asked the Plan to pre-approve a crutch substitute, lower leg platform. You say that the item is necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that canes are covered when specific criteria is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crutch substitute, lower leg platform. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the requested E0118 
is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning 
of a malformed body member. The documentation does not reveal objective physical exam findings that 
indicate that you have the cognitive, physical and functional ability to use the requested E0118 crutch substitute 
safely. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a crutch substitute, lower leg platform have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform (E0118).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
May 27, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you haven't had a 
colonoscopy in 5 years and your doctor felt that you should have another one. You say that you feel this should 
be preventive. The Plan denied your request. The Plan says the copayment 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 $400 
copayment for an outpatient hospital facility. 
 
You have been asked to pay a $400 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 
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 the diagnostic colonoscopy provided on May 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latanoprost. 
 
You asked the Plan to pre-approve Latanoprost. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Latanoprost.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services 
coded 76377 provided on March 27, 2020.
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting 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 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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the submitted documentation 
do not indicate that image postprocessing on an independent workstation was performed. Based on this 
information, we decided that Medicare rules for coverage of the 3D rendering with interpretation and reporting 
services have not been met.  

Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting 
services coded 76377 provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cast application provided on June 5, 
2020.  
 
You asked the Plan to waive the copayment for the cast application. You say that you only had one surgery and 
you do not understand the additional bill. You say that the service was not an additional outpatient surgery. The 
Plan denied your request. The Plan says the copayment 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 $100 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility and physician or surgical charges. 
 
You have been asked to pay a $100 copayment for the cast application. The cast application falls within the 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" 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 the cast application 
provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT Code 64493), injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (CPT Code 64495) and Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT Code 64494).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the services. Our physician reviewer found the patient has both axial pain and radicular pain. The patient has positive Patrick's test and straight leg raising test. Therefore, the patient does not meet the criteria of the LCD and 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT Code 64493), injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (CPT Code 64495) and Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT Code 64494).