Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve the device. You say that the doctor says that this is needed. The Plan denied 
your request. The Plan says the notes do not show a sleep study confirming sleep apnea. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have mild asthma. There is a history of snoring, but there is no complete sleep history. There is no 
documentation of excessive daytime sleepiness. A sleep study on August 17, 2021 showed a normal apnea-
hypopnea index (AHI), so sleep apnea can be ruled out. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 
provided on April 26, 2021.  
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services represented by code 99153 provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study provided on July 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 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 93976 was billed with code 76856. CPT code 93976 may be eligible for payment when 
billed with this code pair. However, the claim does not show that the code at issue was billed with an 
appropriate modifier.  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 vascular study provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram services provided on August 12, 
2020. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 95700 is electroencephalogram (EEG) continuous 
recording, with video when performed, setup, patient education, and takedown when performed, administered 
in person by EEG technologist, minimum of 8 channels. We find that CPT code 95700 is not supported in the 
medical record. Specifically, the records do not indicate the services at issue were administered in-person by an 
EEG technologist.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram services provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and 
contents (72148). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has progressive numbness and loss of 
balance. You are concerned about nerve impingement in the lumber spine and is appealing the denial. The Plan 
denied your request. The Plan says the criteria has not been met due to no notes reporting a trial of physical 
therapy or home exercise. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature indicates that obtaining MR imaging without undergoing a degree of conservative 
treatment and in addition lack of significant clinical findings other than ongoing reported pain, is not medically 
beneficial. The review has determined that the requested MRI is 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on June 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment (E1390) provided June 17, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that the oxygen accessories should be covered as 
you were told after 14 months of rental they would be purchased. The Plan denied your request. The Plan says 
oxygen accessories that are purchased by the beneficiary are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that accessories for beneficiary-owned oxygen 
equipment are non-covered. 
 
We looked at the file and Medicare rules. The items were purchased outright and not rented. Based on this 
information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. 
Therefore, we decided that the Plan does not have to pay for oxygen equipment (E1390) provided June 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on October 
29, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says no separate payment is made for this CPT 
code per Medicare. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B meaning that payment for this service is always bundled into another procedure. Separate 
payment is not made for CPT code 99100. 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 the anesthesia services coded as 99100 provided on October 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (fixed wing) (A0430) and fixed wing air mileage, per statute mile (A0435) provided on April 9, 2021. 
 
You asked the Plan to pay for the air ambulance transportation. You say that the air ambulance transport was 
medically necessary. The Plan denied your request. The Plan says the air ambulance transport services are not 
medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transportation. Our 
reviewer says that the air transport is not medically necessary. Our physician reviewer found the documentation 
did not support that the enrollee suffers from an illness or injury that contraindicates transportation by any 
means other than ambulance. The documentation did not support that the enrollee's condition was such that the 
time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to 
the enrollee's survival or seriously endangered the enrollee's health. The reviewer found that the enrollee was 
hemodynamically stable at the time of transport. The reviewer also found that the documentation did support 
that the transferring hospital did not have adequate facilities to provide the medical services needed by the 
enrollee. Therefore, the reviewer found that the air transport was 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 air ambulance transportation have not been met. Specifically, the file shows 
that the enrollee was stable prior to transport and did not suffer from an illness or injury that contraindicates 
transportation by any means other than ambulance. Therefore, we decided that the Plan does not have to pay 
for the ambulance service, conventional air services, transport, one way (fixed wing) (A0430) and fixed wing 
air mileage, per statute mile (A0435) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the scaling and root planing (D4341 x 4) and extraction (D7140) 
provided on July 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that there are no in network periodontists. You say 
that a plan representative advised there is one, but they are out of state. You say that the plan gave you 
authorization to see the dentist in this case. You say that you went for a follow up treatment, and it was not 
covered. You also say that these services should be covered. The Plan denied your request. The Plan says that 
the provider in this case is out of network. The Plan also says that dental service received 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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have been met. The record shows that a plan representative confirmed there 
were no in network periodontists in your area. Additionally, the record shows that the dates of authorization 
provided for the provider in this case ended on a Saturday. It is reasonable to expect that the next business day 
would be covered under this authorization. Therefore, we decided that the Plan has to pay for the scaling and 
root planing (D4341 x 4) and extraction (D7140) provided on July 12, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services provided on May 28, 2020 
and August 3, 2020. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says they have paid the annual limit allowed 
by your dental plan for the 2020 benefit year. 
 
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. 
 
We looked at the file and the Plan's contract. The plan contract says you have an allowance of $235 for non-
Medicare covered dental services for the 2020 benefit year. The file shows that the Plan paid the annual limit 
for the 2020 benefit year. Therefore, we decided that the Plan does not have to pay additionally for the dental 
services provided on May 28, 2020 and August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is only covered for certain indications. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has neck pain. The enrollee had cervical RFA on January 
28, 2019 and had excellent pain relief that has lasted more than two years. It is required that repeat diagnostic medical branch blocks if it has been more than two years since the RFA. Therefore, the enrollee does not meet 
criteria for the requested 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from May 2, 2020, to May 21, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were 
hospitalized for COVID-19.  You stated that you cannot afford this copayment. The Plan denied your request. 
The Plan says you were charged this copayment 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 $290 
copayment per day for days 1-6, and a $0 copayment per day for days 7-365 for inpatient hospital services.  
  
Records show that you were in the hospital for 19 days.  You were charged a $290 copayment for each of the 
first 6 days of your stay, for a total of $1740.  You were not charged a copayment for the remaining days of 
your stay. 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 inpatient hospital services you received from 
May 2, 2020, to May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on May 4, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you have had many problems with the 
billing from this dental practice and you think the incorrect codes were used. You say that you believe all the 
services should have been covered. The Plan denied your request. The Plan says the intraoral x-ray and resin-
based composite were paid according to your benefits and the limited oral evaluation remains denied as a non- 
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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of skin of nail fold (11765) provided on August 
18, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for an excision of skin of nail fold. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not 
been met. 
 
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 
items/services 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 an excision of skin of nail fold (11765) provided 
on August 18, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for kidney dialysis services(90961, 90960, 
90970) provided from January 1, 2020, to April 1, 2021. 
 
You asked the Plan to waive the coinsurance for kidney dialysis services. You say that you were not supposed 
to have a copayment. The Plan denied your request. The Plan says you were charged the correct cost sharing 
amount. 
 
 
 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 each Medicare-covered outpatient dialysis treatment (including dialysis treatments when 
temporarily out of the service area).  
 
Although you were not charged a copayment, you have been asked to pay $190.42 in coinsurance, which is 
20% of the allowed amount for kidney dialysis services ($962.07 allowed amount x 20% coinsurance = 
192.42). Kidney dialysis services fall within the Services to Treat Kidney Disease 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 coinsurance for kidney dialysis services(90961, 90960, 90970) provided from 
January 1, 2020, to April 1, 2021.