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

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on January 25, 
2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary and rendered in good faith. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 16, 2022. The services in question were provided 
before the end of that month. Additionally, the record shows that the enrollee re-enrolled in hospice before the 
end of the month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99233) provided on January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve syntonic vision therapy. 
 
You asked the Plan to pre-approve syntonic vision therapy. You say that these services are medically necessary 
as you had a concussion which has left lasting balance, speech, memory and coordination problems. The Plan 
denied your request. The Plan says these services are not medically necessary, as this treatment is considered 
experimental/investigative due to limited evidence of efficacy. 
 
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 syntonic vision therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have visual disturbance due to post-concussive state. There is insufficient 
literature to support the use of the requested therapy for your condition. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied; the requested service is not 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 syntonic vision therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve syntonic vision therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have a 
copay for a colonoscopy. You state you've had them before, and did not have a copayment for those, regardless 
of what was done during the test. The Plan denied your request. The Plan says because the provider had to take 
a sample during this colonoscopy, it made the test a diagnostic colonoscopy. 
 
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 $325 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the Outpatient Hospital Services 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 copayment 
for diagnostic colonoscopy provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the request is for the trial. The Plan 
denied your request. The Plan says the enrollee has not failed conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. In this case, the medical records only include the enrollees bladder 
control diary. There are insufficient medical records to show that the enrollee is refractory to conventional 
therapy, or that he is an appropriate surgical candidate. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a sacral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided November 11, 2021 to 
November 16, 2021 billed with DRG 246. 
 
You asked the Plan to pay for the inpatient services billed with DRG 246. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by 
the documentation. 
 
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 J96.01, defined acute respiratory failure with 
hypoxia. 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 services billed with 
DRG 246. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer 
found the documentation supported an admission for non-ST-elevation myocardial infarction (NSTEMI). From 
the information that was received, documentation was inconsistent/unclear regarding a diagnosis of acute 
respiratory failure with hypoxia. Even though acute respiratory failure with hypoxia is documented, supporting 
medical record documentation was not found within the record. While the enrollee presented short of breath, 
discharge summary notes "Oxygen saturation in the 80's that corrected with administration of oxygen via nasal 
cannula". Documentation supports the enrollee was on a maximum of 4 liters of oxygen via nasal cannula on 
this admission. Treatment must be consistent with acute respiratory failure such as administration of oxygen, 5 
liters or more, or provision of bilevel positive airway pressure (BiPAP) or mechanical ventilation. Per history 
and physical provider exam, "no increased work of breathing, good air exchange". History and physical 
examination, provider assessment and plan stated "Pulmonary- No active issues". In addition, there was no 
evidence of arterial blood gases (ABG's) done to support a partial pressure of oxygen in the arterial blood 
(PaO2) of less than 60mm vital signs at rest. As noted above, although the provider documented acute 
respiratory failure with hypoxia, reasonable support within the health record must be present for that diagnosis. 
DRG 246 is not supported by the documentation. The secondary diagnosis of code assignment of J96.01 acute 
respiratory failure with hypoxia is not supported by the documentation.  
 
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 the inpatient services provided November 11, 2021 to November 16, 2021 billed with DRG 246.
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 September 21, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not transported to emergency care and should not be charged $607.50 for this date of service. The Plan denied 
your request. The Plan says the ambulance benefit is a transport benefit, 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 September 21, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actifuse allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of Actifuse allograft in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Actifuse allograft 
remains experimental for use in spinal surgery. More research is needed to show safety and efficacy. Our 
physician reviewer found these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Actifuse allograft for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee needs additional physical 
therapy for range of motion, strength, and prevention of recurrent injury to his rotator cuff and labrum. The 
Plan denied your request. The Plan says the enrollee has had 24 physical therapy visits thus far, and the 
enrollee does not meet the criteria for skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the member had previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of the members medical condition and therefore are not medically 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twelve physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fixed pontic on tooth #30 (D6245) and white glass 
caps on tooth #'s 29 and 31 (D6740) to be provided by a network provider. 
 
You asked the Plan to pre-approve the fixed pontic on tooth #30 (D6245) and the white glass caps on tooth #'s 
29 and 31. You say that the enrollee has an existing bridge that is over ten years old and needs to be replaced. 
You say the enrollee does not want a partial denture. The Plan denied your request. The Plan says the services 
are not medically necessary. 
 
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. The Plan covers the fixed 
pontics (D6245) and white glass caps when the services are medically necessary and reasonable.  
 
 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 fixed pontic on tooth #30 (D6245) 
and the white glass caps on tooth #'s 29 and 31. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found that the Plan's criteria for fixed bridgework requires that the enrollee 
is unable to wear a removable appliance. According to the Plan, fixed bridgework is not commonly allowed 
except where there is documented physical or neurological impairment that precludes the use of a removable 
appliance. In this instance, the replacement bridge is not supported because there is no documentation to 
support the claim of physical or neurological impairment. The Plan criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fixed pontic on tooth #30 (D6245) and the white glass caps on tooth #'s 29 
and 31 have not been met. Therefore, we decided that the Plan does not have to pre-approve the fixed pontic on 
tooth #30 (D6245) and white glass caps on tooth #'s 29 and 31 (D6740) to be provided by a network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are 
necessary for your swollen feet and legs. The Plan denied your request. The Plan says this specific style of 
compression stocking is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional units of CPT code 12001 provided on 
February 2, 2022.  You asked the Plan to pay for the additional units of CPT code 12001. You say that the enrollee received 
sutures on more than one finger, and this should not be denied due to frequency of services. You say that the 
claim should be reviewed for payment of 12001. The Plan denied your request. The Plan says one unit of 
procedure code 12002 has been paid. The Plan also says the additional units of procedure code 12001 remain 
denied as exceeding the allowable units of service for the same date of service. 
 
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 12001 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
additional units of CPT code 12001 have not been met. Therefore, we decided that the Plan does not have to 
pay for the additional units of CPT code 12001 provided on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0652, E0667) provided on 
February 3, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the requested items were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The case record indicates that the items at issue in this appeal were for use outside of the home. Although these 
items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for pneumatic compression devices (E0652, E0667) provided on 
February 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on December 5, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the 
ambulance service, basic life support, non-emergency transport was medically necessary. The Plan denied your 
request. The Plan says the ambulance services were not medically necessary. 
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance service, basic life support, non-emergency 
transport are not medically necessary. Our physician reviewer found that the documentation does not support 
that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) 
were contraindicated for this enrollee. A stretcher van would have been an appropriate means of 
transportation. 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. The enrollee was transported home after a hospitalization and was stable at the time of discharge. There was no 
need for BLS or ALS monitoring or intervention. The documentation does not support that the ambulance 
transport was medically reasonable and necessary for the 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 ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport provided on December 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on December 21, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. Per LCD L35396, CxBladder testing is non-covered when billed with 
code 0012M. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) 
provided on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) of a 
lower extremity provided on March 9, 2022. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that you never had copayments for MRI's 
before. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 up to a maximum of $75 per day for diagnostic radiology services, including MRI's.  
 
You have been asked to pay the maximum of $75 for the MRI, since the 20% coinsurance amount is higher 
($501.36 allowed amount x 20% coinsurance = $100.27). The MRI falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and 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 
for a magnetic resonance imaging (MRI) of a lower extremity provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of CPT code 20526 provided on March 2, 
2022.  You asked the Plan to pay for the additional unit of CPT code 20526. The Plan denied your request. The Plan 
says one unit of procedure code 20526 will be paid. The Plan also says the additional unit of procedure code 
20526 remains denied as exceeding the allowable units of service for the same date of service. 
 
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 20526 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 the 
additional unit of CPT code 20526 have not been met. Therefore, we decided that the Plan does not have to pay 
for the additional unit of CPT code 20526 provided on March 2, 2022.