Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 21, 2021. 
 
You asked the Plan to pay for the physician's services for a therapeutic, prophylactic, or diagnostic injection. 
You say that Opt out simply means the provider does not accept insurance payments and they Opt out of 
all insurances. The Plan denied your request. The Plan says the rendering provider has opted out of Medicare 
and has provided a Medicare Patient Contract agreement that indicates that the member understands and agrees 
that the services rendered by this provider were not and will not be covered by the members Medicare 
Advantage Plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services for a therapeutic, prophylactic, or diagnostic injection provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
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 the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation is covered when specific 
criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has benign prostatic 
hyperplasia (BPH) and lower urinary tract symptoms. He also has incomplete emptying and urge incontinence. 
He has neurogenic bladder related to back/spine surgery. Patients with neurogenic bladder are excluded from 
coverage of the sacral nerve stimulation. The services are not covered. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral nerve stimulation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 23, 2021, to October 25, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that you feel you should not have to pay for 
the self-administered drugs you received in the hospital. You also say that you were not allowed to bring your 
own medications. The Plan denied your request. The Plan says these drugs are not covered under your medical 
coverage. 
 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 pay for the self-administered drugs 
provided in an outpatient setting from October 23, 2021, to October 25, 2021.  
 
Benefits for the self-administered drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing services provided on May 10, 
2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The gene panel was also billed with multiple 
codes. If a single procedure is performed, only one code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing services provided on 
May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
December 21, 2021. 
 
You asked the Plan to pay for the tooth extraction. You say that you have a dental benefit, and this service 
should be covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a vision supply, accessory and/or service 
component of another vision code (V2797) provided on October 27, 2021. 
 
You asked the Plan to reimburse you for vision services. You say that you disagree with the denial, and you 
should have received the $300 allowance from the plan. The Plan denied your request. The Plan says the 
service is a covered benefit, but you have exceeded the maximum benefit for this service. 
 
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 contract says that you receive a $300 allowance for eyeglasses or contact lenses in lieu of 
eyeglasses, every 2 years. 
 
We looked at the file and the Plan's rules. The records show that you received $300 for vision services on July 
29, 2020. The EOC confirms you receive a $300 allowance for eyeglasses every 2 years; therefore, you have 
exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules 
for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for a vision supply, accessory and/or service component of another vision code (V2797) 
provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.  
 PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0985), provided on October 22, 
2021, by a provider not certified with Medicare. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the item should be covered. The Plan 
denied your request. The Plan says you obtained this item through a provider who is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0985), 
provided on October 22, 2021, by a provider not certified with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair with accessories 
(K0861, E2615, E0956, E1028, E2624, E2377, E2313, E0955, K0108, E0953). 
 
You asked the Plan to pre-approve the replacement power wheelchair with accessories. You say that the 
replacement power wheelchair is medically necessary. The Plan denied your request. The Plan says the existing 
power chair is less than 5 years old. A replacement is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment (less than 5 years). Rules also state that if a power wheelchair 
base is not covered, then related accessories will be denied. 
 
We looked at the file and Medicare rules. The record shows the enrollee has a power wheelchair that is less 
than 5 years old. A replacement is not covered. Since the wheelchair is non-covered, the requested accessories 
are also non-covered. Based on this information, we decided that Medicare rules for coverage of the 
replacement power wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair with accessories (K0861, E2615, E0956, E1028, 
E2624, E2377, E2313, E0955, K0108, E0953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95913) and needle 
electromyography (95886), provided on August 10, 2021, by a chiropractor. 
 
You asked the Plan to pay for the chiropractic services. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies (95913) and needle electromyography (95886), 
provided on August 10, 2021, by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a very heavy-duty group 2 power wheelchair (K0827). 
 
You asked the Plan to pre-approve a very heavy-duty group 2 power wheelchair. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a very heavy-duty power wheelchair is covered 
for beneficiaries who weigh between 428 and 600 pounds. 
 
We looked at the file and Medicare rules. In this case, the enrollee does not weigh between 428 and 600 
pounds. Based on this information, we decided that Medicare rules for coverage of a very heavy duty group 2 
power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a very 
heavy-duty group 2 power wheelchair (K0827).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from May 2, 2021, to May 10, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were not billed as required. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. More than 3 days prior to inpatient admission were billed on the claim at 
issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for the hospital services provided from May 
2, 2021, to May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and extraction (D7140), 
provided on October 25, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you received these services through a provider who has opted out of 
Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
limited oral evaluation (D0140), and extraction (D7140), provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058) provided on December 7, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that you understand the implants are not covered, but would like the crown to be reconsidered 
for coverage. 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 Plans 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 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on 
December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography with doppler complete 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no new or worsening symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at issue in this appropriateness and medical necessity of a transthoracic echocardiography (TTE) in the 
absence of any new or worsening symptoms, according to the submitted records. The clinical guidelines do not 
support carrying out a TTE in this setting. In summary, there is no supportive evidence for the medical 
necessity of a TTE in this this patients clinical management. 
 
 
 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 transthoracic echocardiography with doppler complete for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 18, 2021, to July 
20, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
 
  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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 18, 2021, to July 20, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on May 16, 2021. 
 
You asked the Plan to pay for critical care (99291). You say that this claim is for an inpatient physician. You 
say that the supporting documentation should reviewed, and the decision should be reassessed. The Plan denied 
your request. The Plan says CPT code 99291 provided on May 15, 2021, has been overturned. The Plan also 
says that CPT code 99291 provided on May 16, 2021, cannot be verified as the documentation submitted does 
not include a critical care progress note for the billed date of service. 
 
  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, medical records to support 
that a critical care service was provided on May 16, 2021, were not submitted. Therefore, CPT code 99291 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care 
(99291) have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) 
provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic images (D0350 x 4), panoramic x-ray 
(D0330), and oral hygiene instruction (D1330) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you took the necessary steps to have your teeth 
cleaned without a copay. You say that you received a bill for services that you were not consulted on. You also 
say that you feel these services should be covered. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D photographic images and oral 
hygiene instruction are not among those covered under this benefit. The record shows that panoramic x-ray 
shares a frequency limit of once every 3 calendar years with a diagnostic x-ray. The record shows that the Plan 
paid for a diagnostic x-ray that you received on the date of service in this case. Therefore, we decided that the 
Plan does not have to pay for the 2D photographic images (D0350 x 4), panoramic x-ray (D0330), and oral 
hygiene instruction (D1330) provided on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient mental health admission. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the admission is 
medically necessary. The Plan denied your request. The Plan says that the inpatient mental health admission 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 pre-approve inpatient psychiatric hospital services. 
Our reviewer says that the inpatient mental health admission is not medically necessary. Our physician 
reviewer found the records provided it was expected this enrollee would improve in a reasonable period of time 
although he did not have dangerousness to self or others, auditory or visual hallucinations. The reviewer found 
that the enrollee did appear to require inpatient mental health treatment as although he was not a danger to 
himself but possibly others. The enrollee was found to be noncompliant. The documentation indicates that 
active treatment was taking place. The documentation indicates that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis. Therefore, the reviewer found that inpatient 
mental health admission is medically reasonable and 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve an inpatient mental health admission.  
 
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.