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

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not had this procedure done before so 
it does not exceed the limitations. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 19, 2017. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix (J9303). 
 
You asked the Plan to pre-approve Vectibix. You say that the enrollee's condition has been stable on this 
medication. 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 may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vectibix. Our reviewer says that the 
requested drug, Vectibix, is not medically necessary. Our physician reviewer found he record indicates that the 
enrollee's metastatic disease has progressed while receiving the requested drug. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The reviewer 
found that Medicare approved cancer drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not 
medically neecessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix (J9303).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer with compressor (E0570) provided on August 
14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nebulizer with compressor. You say that the enrollee has had this equipment 
in their home since February 14, 2022, which the Plan has been paying the claims. To remove the equipment 
from the home at this point would be unfavorable to the enrollee's health. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 
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 nebulizer with compressor (E0570) provided 
on August 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient visit (99205) provided on June 29, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not payable as a 
new patient visit. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter".  
We find that CPT code 99205 is not supported in the medical record. Specifically, the records show that the 
enrollee was see by this provider within the previous three years. As such, it is inappropriate to bill a new 
patient visit for the services provided. Based on this information, we decided that Medicare rules for coverage 
of the visit have not been met. Therefore, we decided that the Plan does not have to pay for the new patient 
visit (99205) provided on June 29, 2022.
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. The Plan denied your request. The Plan says your ongoing skilled 
therapy and nursing needs can be provided safely at a lower level of care such as at a Skilled Nursing Facility, 
on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 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.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intense pulsed light therapy. 
 
You asked the Plan to pre-approve intense pulsed light therapy. You say that your eye dryness leads to painful 
episodes which can result in eye damage. You say that you have tried different prescriptions, compresses, 
special massage, face yoga, and supplements. You also say that eye drops, eye gels, and ointments only 
provided minimal and short-lived relief. The Plan denied your request. The Plan says the requested treatment 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 intense pulsed light therapy. Our 
reviewer says that the requested intense pulsed light therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is not enough medical evidence to show if this type 
of treatment brings better results than the usual treatments. Therefore, the reviewer found that the requested 
intense pulsed light therapy 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 intense pulsed light therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intense pulsed light therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need a shower chair because you have 
limited mobility. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 26, 2022, to 
February 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of secondary diagnosis code J96.21: acute & chronic respiratory failure 
with hypoxia with DRG 190. The Plan denied your request. The Plan says the medical records do not support 
the billing of secondary diagnosis code J96.21: acute & chronic respiratory failure with hypoxia with DRG 
190. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of secondary diagnosis code J96.21: acute & chronic 
respiratory failure with hypoxia with DRG 190. Our physician reviewer found the documentation indicates that 
the enrollee presented to the emergency department (ED) with complaints of increased shortness of breath. 
Vital signs in the ED were T98.8, HR70, RR20, BP113/51, and an oxygen saturation level of 100% on 3L. On 
physical exam, the ED physician notes Distress: no apparent. Respiratory Exam: other (slightly increased 
work of breathing without tachypnea), No: CTAB (Quiet breath sounds, unable to appreciate wheeze rales or 
rhonchi). The physician further documented The patients O2 saturation on 3L is consistently 100%, when 
brought down to 2L it is 97 to 98%. An arterial blood gas (ABG) test shows appropriate oxygenation and CO2 
not significantly elevated. His chest x-ray showed no acute cardiopulmonary process. The member was treated 
with DuoNebs and steroids, remained hemodynamically stable, observed overnight, and discharged home the 
following day. In this case, there was no clinical or laboratory evidence of acute/chronic respiratory failure 
with hypoxia. The review has determined that the documentation did not support J96.21.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 26, 2022, to February 27, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the admit date submitted on 
the claim is February 7, 2022; however, an NOA has not been submitted with this date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that an NOA has not been submitted to match the 
admission date on the denied claim. Based on this information, we find that the Medicare rules for payment of 
the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from March 9, 2022, to April 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on April 21, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
you believe this is an inaccuracy due to the Plan's billing guidelines and policy. The Plan denied your request. 
The Plan says the documentation does not support medical necessity. 
 
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 service, basic life support, 
non-emergency transport. Our reviewer says that the service is not medically necessary.  
 Our physician reviewer found the record indicates that the enrollee was transported via stretcher. The record 
does not indicate that the enrollee's clinical condition is such that other methods of transport, such as stretcher 
are contraindicated or that the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide was required. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on April 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service January 
26, 2022. 
 You asked the Plan to pay for procedure code(s) 88381. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88381 has a Professional/Technical indicator of 1. This means that CPT code 88381 has 
both a professional and technical component. In this case, CPT code 88381 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88381 billed for date of service January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered scooter. 
 
You asked the Plan to pre-approve a powered scooter. You say that you have COPD, and you are frequently 
out of breath. You get winded going from your bedroom to the kitchen, and you use oxygen at night. The 
recommendation of a wheeled walker with a seat will make you use your arms, and it will still get you winded. 
The Plan denied your request. The Plan says you do not meet the criteria for a scooter or a powered wheelchair. 
PO2 is 93 to 95% on room air. You use O2 only at night, you have shortness of breath with exertion, seems 
related to obesity and deconditioning. No significant related rheumatological or orthopedic issues. Thus, a 
power scooter is for your convenience rather than a medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 powered scooter. Our reviewer says 
that the service is not medically reasonable or necessary. Our physician reviewer found you use nocturnal 
supplemental oxygen therapy but do not require oxygen for activity. The documentation indicates you are able 
to ambulate independently with the use of a walker and require assistance for longer distances. There is no 
indication the power scooter is required to accomplish mobility-related self-care tasks in the home. The 
documentation indicates you can use alternative assistive devices in the home to accomplish mobility-related 
self-care tasks. The requested power scooter is not needed in the home; therefore, you do not meet criteria for 
approval. 
 
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 powered scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered scooter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for a total hip arthroplasty (01214) provided on 
January 28, 2022. 
 
You asked the Plan to pay for anesthesia for a total hip arthroplasty (01214). The Plan denied your request. The 
Plan says original Medicare is responsible for payment. 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for anesthesia for a total hip arthroplasty (01214) provided on 
January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment 
for code 70551.  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 70544 
is a column II code to column I code 70551. 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 procedure code 70544 billed for date of service July 28, 2022.