Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 7, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy (43249) provided on August 
12, 2021. 
 
You asked the Plan to pay for esophagogastroduodenoscopy. You say that this service is supported in the 
record and should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives 
(NCCI) Procedure to Procedure (PTP) edit exists between 43270 and 43239.  This PTP edit has a modifier indicator of 0, meaning modifiers associated with NCCI are not allowed. It is 
inappropriate for these two codes to be billed together. 
 
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, we have confirmed that code 43239 
is a column II code to column I code 43270. This code pair does not allow for a modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for esophagogastroduodenoscopy (43249) provided on August 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on November 11, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on November 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 9, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says the POS code reported is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the definitive drug testing provided on April 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast injection. 
 
You asked the Plan to pre-approve Reclast. You say that you need this injection for your bones. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reclast. Our reviewer says that the 
requested Reclast injection is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the request for Reclast injection is 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 Reclast have not been met.  
 
 
 
 Additionally, the file shows that the plan contacted your Primary Care Physician's office, medical assistant 
explained that the provider does not want to change your current treatment for Osteoporosis. Therefore, we 
decided that the Plan does not have to pre-approve Reclast injection.
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 admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission 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 provided documentation does not indicate that the enrollee has complex nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on December 16, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on December 16, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from October 13, 2021, 
to October 14, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that this procedure was necessary to unblock your 
blood vessel. You say that this was necessary in order to complete your dialysis. You also say that you need 
help with this bill. The Plan denied your request. The Plan says the claim was denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care have been 
met. Specifically, there have been no medical records provided to support that the services in this case were 
medically necessary. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care 
provided from October 13, 2021, to October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance the back brace provided by a network 
provider on November 30, 2021. 
 
You asked the Plan to waive the coinsurance the back brace. You say that your insurance plan covers medical 
equipment 100%, and you should not be charged. The Plan denied your request. The Plan says you have been 
asked to pay 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 20% 
coinsurance for Medicare-covered prosthetic devices, related supplies related to prosthetic devices, and 
orthotics.  You have been asked to pay $98.93 which is 20% of the allowed amount for the back brace. The allowed 
amount is $494.67. ($494.67 x 20% = $98.93). The back brace falls within the Prosthetic devices and related 
supplies 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 the back brace provided by a 
network provider on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is clearly not meeting the minimum requirements for usage of the device. 
 
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 the documentation does not support that the CPAP machine was used for at least 4 hours per night on 
70% of nights during the trial period. There are no clinical records to support that the enrollee had a face-to-
face visit with the provider after a three month trial period. 
 
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 continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 13, 2021. 
 
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 services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93042 (insertion of non-tunneled centrally inserted central 
venous catheter) and 36556 (rhythm ECG, 1-3 leads, interpretation and report only). Code 93042 is a column II 
code with a modifier indicator of 1 when billed with column I code 36556. Code 93042 was not billed with an 
appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay 
for the surgical services rendered on September 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 26, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee collapsed, broke a rib, and was hospitalized for 9 days. You also say that the enrollee had 4 blood 
transfusions while hospitalized, was very weak, and needed transport to and from the hospital. The Plan denied 
your request. The Plan says the ambulance benefit is a transport benefit. The Plan also says that if no transport 
of a Medicare beneficiary occurs, then there is no Medicare covered service. 
 
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 October 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that the Plan confirmed with the provider that the enrollee refused transport to the hospital. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 26, 2021.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission 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 you do not have complex nursing or rehabilitation needs. The reviewer found while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. The reviewer also found that there is not a reasonable expectation that you will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Therefore, the reviewer found that the requested IRF admission 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites of one surface (D2391 x2) 
and resin-based composite of two surfaces (D2392) provided on December 9, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the resin-based composites. You say that the provider verified your insurance 
eligibility. You also say that the office staff gave you an estimate of what you would have to pay after your 
insurance plan paid their portion. The Plan denied your request. The Plan says these services cannot be covered 
because they were rendered by an OON provider. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the two resin-based composites of one surface (D2391 x2) and resin-based composite of two surfaces 
(D2392) provided on December 9, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005) and 
accessories 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 this is not medically necessary. 
 
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 the wheelchair assessment does not reveal detailed objective measurements of doorways. The assessment 
states that the bathroom door is too narrow for the wheelchair. There is a need for another transport chair to get 
into the bathroom. The document was not clear whether the requested ultra-lightweight wheelchair will fit in 
the bathroom doorway for MRADLs therefore it is not clear if the home is fully appropriate for the wheelchair 
for MRADL participation. The documentation is not clear that the specific ultralightweight wheelchair 
will significantly improve the patient's ability to participate in MRADLs over a standard wheelchair. The 
documentation is not specific whether the patient is unable to self-propel a standard wheelchair but states the 
patient is expected to self-propel the requested wheelchair. The patient is a full time wheelchair user. The 
physician progress notes are not specific that the patient requires individualized fitting and adjustments for one 
or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, which 
cannot be accommodated by a K0001 through K0004 manual wheelchair. Also the wheelchair assessment form states that the patient is using a loaner wheelchair. It is not clear that the 
patient is unable to effectively use an appropriately fitted standard manual wheelchair. The criteria for a ultra-
lightweight manual wheelchair (K0005) and accessories have not been met. 
 
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 an ultra-lightweight manual wheelchair (K0005) and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #11 (D2950), precision 
attachments (D5862), or a partial overdenture (D5266). 
 
You asked the Plan to pre-approve core build up on tooth #11 (D2950), precision attachments (D5862), and a 
partial overdenture (D5866). You say that the requested services are medically necessary. The Plan denied your 
request. The Plan says the core build up on tooth #11 is not medically necessary. The Plan also says that 
precision attachments, and a partial overdenture are not covered benefits. 
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 a core build up on tooth #11. Our 
reviewer says that the core build up for tooth #11 is not considered medically reasonable and necessary. Our 
physician reviewer found the remaining tooth structure appears adequate to support and retain a crown 
restoration. 
 
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 core build up on tooth #11 has not been met. Additionally, precision 
attachments, and a partial overdenture are not covered benefits. Therefore, we decided that the Plan does not 
have to pre-approve core build up on tooth #11 (D2950), precision attachments (D5862), or a partial 
overdenture (D5266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) and consultation (D9310) 
provided on August 26, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the simple extraction and consultation. The Plan denied your request. The Plan 
says these services were rendered by a provider who chose not to receive Medicare funds. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the simple extraction (D7140) and consultation (D9310) provided on August 26, 
2021 by a Medicare opt out provider.