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

 
We decided that the Plan does not have to pay for the ambulance transportation provided on March 24, 2021. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a 
covered destination. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the requested ambulance services are not medically reasonable and necessary. Our physician reviewer 
found that the documentation does not support that other means of transport (such as stretcher van) were 
contraindicated for this enrollee on March 24, 2021. The documentation does not support that the enrollee 
needed the expertise, services, and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. No treatments were administered. Vitals were stable. The 
documentation does not support that the ambulance transport was medically reasonable and necessary for this enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance transportation provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on June 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the claim was processed incorrectly. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 4, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift (E0627, S9999) purchased on May 22, 2021. 
 
You asked the Plan to pay for a seat lift. You say that you purchased this before knowing it could be covered 
by your insurance. The Plan denied your request. The Plan says this was not purchased from a supplier that is 
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 a seat lift (E0627, S9999) purchased on 
May 22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic shoes with inserts 
 
You asked the Plan to pre-approve the shoes. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules state that supportive devices for the feet (such as 
orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace.  
 
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 shoes. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found 
it is well established in the medical documentation that you suffer from diabetes with bilateral lower extremity 
peripheral neuropathy. You are noted to have diminished pedal pulses, rather 1/4 bilaterally. Your skin is noted 
to be atrophic bilateral lower extremity. Finally, you are noted to have calluses to the medial aspect bilateral 
heels, which could potentially ulcerate. In order for diabetic shoes and diabetic insoles to be covered, specific 
criteria must be met. These specific criteria have been met according to the records.  
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 shoes have been met. Therefore, we decided that the Plan has to pre-approve 
diabetic shoes with inserts  
 
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: Favorable

We decided that the Plan has to pre-approve a repeat sacroiliac joint injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no contractual obligation to cover services that are not medically necessary.

The Plan must follow Medicare rules. The rules say that a positive response for sacroiliac (SI) joint injections would be considered pain relief greater than 75%. 

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 injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the prior diagnostic injection identified the pain generator and provided 100% pain relief. This meets the criteria, making the request 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve a repeat sacroiliac joint injection for the enrollee.

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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stress test provided on February 25, 2021. 
 
You asked the Plan to pay for the stress test. You say that your employer requires a stress test every 2 years. 
You say that the stress tests were always covered under your previous doctor. You say that you switched 
doctors because this one is much closer to you. You also say that your doctor's office never advised there may 
be an issue. The Plan denied your request. The Plan says the claim processed correctly as physical exams and 
other services required by third parties such as obtaining or maintaining employment or participation in 
employee programs, required for insurance or licensing are not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the stress test have not been met. The record shows that the stress test was required for clearance 
for your job. The Evidence of Coverage clearly states that physical exams and other services required by third 
parties are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the stress test 
provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), periapical x-ray (D0220), and unspecified preventive service (D1999), provided on June 14, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you chose this plan based on your doctors being 
in the network. You say that when you left your appointment, the provider's office advised they were having 
trouble with your plan. You say that you feel that you have been misled. You say that the plan advised they 
have not dropped the provider, yet the services are not being covered. You also say that you should be 
reimbursed for these services. The Plan denied your request. The Plan says the provider in this case is out of 
network, effective December 31, 2020. The Plan says that dental services received out of network are not 
covered. The Plan also says that unspecified preventive service is not listed as a covered service. 
 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 and the exam, prophylaxis, and x-rays 
are listed as covered, dental services received out of network are not among those covered under this benefit. 
Additionally, unspecified preventive service is not among those covered under this benefit regardless of the 
provider's network status. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), 
prophylaxis (D1110), bitewing x-rays (D0274), periapical x-ray (D0220), and unspecified preventive service 
(D1999), provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ROMTech Portable Connect rehabilitation device. 
 
You asked the Plan to pre-approve the ROMTech Portable Connect rehabilitation device. You say that the 
requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage 
have not been met because studies have not shown helpfulness for knee rehabilitation for non-homebound 
patients. 
 
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 ROMTech Portable Connect 
rehabilitation device. Our reviewer says that the requested item is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you are being treated for unilateral primary 
osteoarthritis of the left knee. You are planned to undergo a left total knee arthroplasty. Exam reveals non-
antalgic gait with varus thrust, left knee. There is 15 degrees varus deformity that is fixed. Range of motion is 0 
to 135 degrees. However, there is limited published, large-scale, long-term peer-reviewed literature that shows 
the requested item to be an effective and/or safe treatment for the noted pathology.  
  
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
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 ROMTech Portable Connect rehabilitation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the ROMTech Portable Connect 
rehabilitation device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram report provided on April 5, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the treatment is entitled to payment. The Plan 
denied your request. The Plan says there are no modifiers that are allowed with this code pair. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 93042 was billed with code 99291. This code pair has a modifier indicator of 0. If the 
correct coding modifier indicator of a PTP edit is "0", the Column Two code is not eligible for payment even if 
an NCCI PTP-associated modifier is appropriately appended to one of the codes. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the rhythm electrocardiogram report provided on April 5, 2021.
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), for the enrollee. 
 You asked the Plan to pre-approve the injection. You say that the enrollee's first lumber MBB was rendered on 
October 21, 2021. You state you are requesting this as urgent for the second lumbar MBB since it have been 
longer than two (2) weeks since the first lumbar MBB. The Plan denied your request. The Plan says the 
Medicare rules have not been 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 the injection. Our physician reviewer 
found the record indicates that the enrollee underwent a medial-branch block at L5 on October 21, 2021, for 
which the degree of pain relief is not recorded in the record.  A note is submitted after notification of denial 
without medical record support, that an 80% improvement was noted. The record does not indicate why the 
second block must be performed prior to the two-week waiting period. The enrollee underwent a diagnostic 
block at L1-L2 in September 2021 that provided no pain relief. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
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 injection 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), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043, 11046) and the 
home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network 
(OON) provider on June 7, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the muscle and/or fascia debridement (11043, 11046) and the home visit for the 
evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider 
on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas treatment. 
 
You asked the Plan to pay for Sanexas treatment. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy 
services only if they are furnished by or under the supervision of a physical therapist in private practice; or by, 
or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical services under state law. Medicare rules say that compounded drugs shall be submitted using 
a compounded drug, not otherwise classified (NOC) code. 
 
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide 
physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled 
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Because the drugs are not paid as billed, the drug administration code also cannot be paid. Based on this 
information, we decided that Medicare rules for coverage of Sanexas treatment have not been met. Therefore, 
we decided that the Plan does not have to pay for Sanexas treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical additional radiographic images (D0230 x 2) 
provided on June 14, 2021. 
 
You asked the Plan to pay for periapical additional radiographic images. You say that during your annual 
dental cleaning, you ask the provider not to take x-rays that the Plan will not pay for. You are requesting a 
reconsideration of the denied charges. The Plan denied your request. The Plan says periapical radiographic 
images are covered once per calendar 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. The Plan covers periapical 
radiographic images once per calendar year.  
 
 We looked at the file and Medicare rules. The records show you were reimbursed for one periapical 
radiographic image on the same date of service and the EOC confirms you are allowed a periapical 
radiographic image once every calendar year. Based on this information, we decided that the Plan's rules for 
coverage of periapical additional radiographic images have not been met. Therefore, we decided that the Plan 
does not have to pay for periapical additional radiographic images (D0230 x 2) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge services (99217) provided on 
July 3, 2021. 
 
You asked the Plan to pay for the observation care discharge services. You say that you would like 
reconsideration because this claim denied in error. The Plan denied your request. The Plan says since a qualifying initial or subsequent observation care service was not found in the member's claims history, this 
discharge service (99217) denied. 
 
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 99217 is not supported in the record. Specifically, the record does not indicate that a 
qualifying observation care service was billed by this provider. Based on this information, we decided that 
Medicare rules for coverage of the observation care discharge services have not been met. Therefore, we 
decided that the Plan does not have to pay for the observation care discharge services (99217) provided on July 
3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5226) provided on June 14, 
2021. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you feel the flexible partial you 
received will prolong losing your tooth, which you need for better chewing. You also say that you would like to 
receive a partial payment of 50% for this partial. The Plan denied your request. The Plan says this service is not 
covered by the 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 
mandibular partial denture (D5226) provided on June 14, 2021.