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

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 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 covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teeth extractions for #3, #4, #5, #11, #12, #13, #14, #15, and 
#16 provided by a participating provider on December 27, 2021. 
 
You asked the Plan to pay for teeth extractions. You say that you should not have to pay for anything. The Plan 
denied your request. The Plan says the benefit limit for extractions has already been met. 
 
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 three teeth 
extractions per year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of teeth extractions have already been met. Therefore, we decided that the Plan does not have to pay 
for teeth extractions for #3, #4, #5, #11, #12, #13, #14, #15, and #16 provided by a participating provider on 
December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310), and a cone beam 
capture (D0367) provided by an out-of-network provider on June 18, 2021. 
 
You asked the Plan to pay for a diagnostic service consultation and a cone beam capture. You say that you told 
the dentist not to provide any services that were not covered. The Plan denied your request. The Plan says 
D9310 and D0367 are not covered dental benefits. 
 
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 a diagnostic service consultation (D9310), and a cone beam capture (D0367) provided by an out-of-network 
provider on June 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on June 12, 
2021. 
 
You asked the Plan to pay for the services. You say that it would have been unsafe to be transported to the 
emergency room. The Plan denied your request. The Plan says the plan covers ambulance transportation only 
when you are actually transported by 
ambulance. 
 
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 June 12, 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 ambulance services provided to the enrollee on 
June 12, 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 enrollee is suitable for transfer to the 
LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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. The 
enrollee does not require services at the LTACH that are not available at the current acute care facility. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for a physician office visit provided on September 14, 
2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that you have never had a service of any 
kind from the provider. The Plan denied your request. The Plan says that you have been charged the correct 
cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide accurate medical records to confirm that services took 
place on September 14, 2021. Without accurate medical records we are unable to determine if the cost share 
applied is correct. Therefore, we decided that the Plan has to waive the deductible for a physician office visit 
provided on September 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of total knee arthroplasty (27487) provided by 
on May 25, 2021. 
 
You asked the Plan to pay for the revision of total knee arthroplasty (27487). You say that procedure code 
27487 is stated in the operative report and the report should be reviewed in a more detailed matter. The Plan 
denied your request. The Plan says procedure code 27487-RT is not supported by the medical records 
submitted. 
 
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 27487 is revision of total knee arthroplasty, with or 
without allograft; femoral and entire tibial component. 
  We asked our coder 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 revision of total knee arthroplasty (27487). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the operative report does not include enough documentation to confirm a total knee revision was 
performed to include femoral, tibial, and patellar components. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the revision of total knee arthroplasty (27487) have not been met. Therefore, we 
decided that the Plan does not have to pay for the revision of total knee arthroplasty (27487) provided by on 
May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93042) and services provided 
between 10:00 PM and 8:00 AM at a 24-hour facility (99053) provided on July 6, 2021. 
 
You asked the Plan to pay for the electrocardiogram and services provided between 10:00 PM and 8:00 AM. 
You say that you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the payment for CPT codes 93042 and 99053 is bundled into the payment for other services. 
 
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 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, CPT code 99053 has a status indicator of B. This means that payment for CPT 
code 99053 is always bundled into the payment for another service or procedure. 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 
electrocardiogram (93042) and services provided between 10:00 PM and 8:00 AM at a 24-hour facility (99053) 
provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve the Myopro device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is experimental. 
 
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 Myopro device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will improve the long 
term outcomes for you, improve hemiparetic arm function, or be safe for long term use.  There is also insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 Myopro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you may be safely and equally well served at an alternative level of 
care. 
 
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. 
 You are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no rehab nursing needs identified or documented in the record. At the current 
level of function, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary 
management and the needs can be met in an alternate and lower setting. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF care. 
 
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: 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 appears to be improving and should only require short-term additional 
acute care services that can safely be completed at the current facility until more appropriate for a lower level 
of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to a lower level of care may be considered soon when treatment is 
completed. 
 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various inpatient-related services provided to the enrollee 
from March 11, 2021 to April 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the items denied for unbundling include arterial puncture, assisting with intubation, emergency 
intubation, blood collection, transfusions, respiratory treatments, catheters, guidewires, introducers, point of 
care glucose, venipuncture, micropuncture, COVID testing, central line insertion, and a micropuncture kit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
 
 We find that the still denied supplies and services are not supported in the medical record. Specifically, the 
inpatient services themselves were paid for. The various other services still at issue in this cannot be paid 
separately from the inpatient claim payment. 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 pay for 
various inpatient-related services provided to the enrollee from March 11, 2021 to April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 11 non-emergent taxi trips (A0100 x11) 
provided from September 2, 2021, to October 26, 2021. 
 
You asked the Plan to waive the copayments for the taxi trips. You say that you feel you should not be charged 
for these transports because the service was terrible. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up-to 24 one-way routine trips for non-emergency, medical-related purposes, and you 
must pay a $10 copay per one-way trip.  
 
You have been asked to pay a $10 copay per taxi trip. 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 copayments for 
11 non-emergent taxi trips (A0100 x11) provided from September 2, 2021, to October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided during a colonoscopy on 
December 8, 2021, billed with code 00811. 
 
You asked the Plan to pay for the anesthesia services. You say that this claim should not be considered bundled 
with any other. The Plan denied your request. The Plan says the same billing provider also billed for 45380. Per 
coding edits, these two codes cannot be billed by the same provider on the same date of service. 
 
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 00811 is Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified. 
 
 We find that CPT code 00811 is not supported in the medical record. Specifically, only a record of the 
colonoscopy was submitted for review, with no anesthesia notes. The procedure note only indicates that a 
certified registered nurse anesthetist (CRNA), but it is not documented that the CRNA reported on the claim 
was the rendering provider. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services provided during a colonoscopy on December 8, 2021, billed with code 00811.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health services provided on November 29, 2021 to 
December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Home Health services provided on November 29, 
2021 to December 9, 2021 by an out-of-network (OON) provider.
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 appears to be more stable and improving and should only require short-
term additional acute care services that can safely be completed at the current facility until more appropriate for 
a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered soon when 
treatment is completed. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Wound care services on November 30, 
2021. 
 
You asked the Plan to waive the copayment for Wound care services. You say that you are wondering why this 
is being billed as a surgical service. The Plan denied your request. The Plan says the copayment is correct since 
the CPT code, 11042, is a surgical code. 
 
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 $175 
copayment for Wound care services.  
 
You have been asked to pay a $175 copayment for Wound care services. Wound care services falls within the 
Outpatient surgery 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 Wound care services 
on November 30, 2021.