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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre kit 2 sensor. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre kit 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre kit 2 sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
having heart palpitations and you were nervous you were going into atrial fibrillation so you called the 
ambulance. You say that your husband arrived before the ambulance and calmed you down. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
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 July 26, 2022. 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 provided on July 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic visit provided on August 9, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric diagnostic visit. You say that an authorization should be on file at 
the facility. The Plan denied your request. The Plan says no authorization was obtained prior to services 
provided. 
 
 
 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 a psychiatric diagnostic visit provided on August 
9, 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 tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on July 5, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Tdap vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715) and administration (90471) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, bite-wing x-rays, 
panoramic x-ray, and a cleaning, (D0274, D1110, D0150, D0330) provided on November 18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation, bite-wing 
x-rays, panoramic x-ray, and a cleaning, (D0274, D1110, D0150, D0330) provided on November 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need acute rehab because you were independent 
and active before coming to the hospital. You say that you can participate and complete the required 3 hours of 
therapy that you will not get in a nursing home. You say that you need close medical management for your 
current medical needs and disease. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met at an alternate 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. Our 
physician reviewer found that you do not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. While you can benefit from physical 
and occupational therapy, your needs can be safely provided in an alternate level of care such as a skilled 
nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry laboratory service provided on August 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a podiatry laboratory service . You say that the records attached support the 
services provided. The Plan denied your request. The Plan says the services can be obtained from an in-
network provider. 
 
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 a podiatry laboratory service provided on August 
26, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from 
September 23, 2022, through September 28, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from September 23, 2022, through September 28, 2022.  
 Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehab to help rebuild your strength and to 
be taken care of accordingly. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can safely receive the care you need at an alternate 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. Our 
physician reviewer found that you do not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. While you can benefit from physical 
and occupational therapy, your needs can be safely provided in an alternate level of care such as a skilled 
nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on January 3, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the record indicates the 
member was enrolled in hospice during the date of service. 
 
  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 a CT scan provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810) 
provided from June 13, 2022, through August 15, 2022. 
 
You asked the Plan to issue reimbursement 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 
provided do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
provided on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to issue reimbursement for the acupuncture treatments (97810) provided from June 13, 2022, through 
August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received by providers who have 
performed biopsies. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (EMG) (95865) provided on 
July 27, 2022. 
 You asked the Plan to pay for the needle EMG. You say that the surgeon determined that this service was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the diagnosis that the 
provider billed, Hyperparathyroidism, unspecified, is not on the list of common disorders where an EMG 
would be helpful in diagnosing. 
 
The Plan follows Medicare rules. Medicare rules say that a list of common disorders is provided in the 
Medicare rules section of this letter where an EMG, in tandem with properly conducted nerve conduction 
studies (NCS), will be helpful in diagnosis. 
 
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 needle EMG. Our reviewer says that the 
needle electromyography (EMG) does not meet Medicare criteria for coverage at this time. Our physician 
reviewer found the enrollee underwent thyroid surgery. This not an indication supported within the applicable 
Local Coverage Determination (LCD) for which EMG monitoring was covered. Our reviewer found that the 
enrollee does not otherwise have a condition for which the LCD supports EMG as a diagnostic modality. Our 
physician reviewer also found that as there was not a problem with the nerve in question, it was not a 
"diagnostic" procedure for which this type of testing is covered. 
 
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 needle EMG have not been met. Therefore, we decided that the Plan does 
not have to pay for the needle electromyography (EMG) (95865) provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, panoramic 
radiographic image, and a 2D oral/facial photographic image (D0150, D0210, D0330, D0350) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the comprehensive oral 
evaluation, intraoral x-ray, panoramic radiographic image had already been exhausted. Coverage for the 2D 
oral/facial photographic image denied correctly as it does not fall within your 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, 
panoramic radiographic image, and a 2D oral/facial photographic image (D0150, D0210, D0330, D0350) 
provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an observation visit provided on August 17, 2022, to August 
19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an observation visit. You say that it is the responsibility of the facility to obtain 
prior authorization. The Plan denied your request. The Plan says there is no authorization on file for the 
services provided. 
 
 
 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 an observation visit provided on August 17, 2022, 
to August 19, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you would like this claim to 
be reconsidered and reprocessed for payment. The Plan denied your request. The Plan says the documentation 
received does not indicate that the enrollee received the screening study for one of the risk categories of a 
family history of abdominal aortic aneurysm, a man aged 65 to 75 who has smoked at least 100 cigarettes in his 
lifetime, or other risk factors recommended. 
 
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. 
 
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 ultrasound of the abdominal aorta. Our 
reviewer says that the criteria for coverage for the ultrasound of the abdominal aorta have not been met. Our 
physician reviewer found a one-time ultrasound screening requires a history of a male patient with a lifetime 
smoking history of at least 100 cigarettes, family history of abdominal aortic aneurysm (AAA) or personal 
medical history placing him at risk for AAA. Our reviewer found that such a history is required in the dictated 
report to qualify for reimbursement. Our physician reviewer also found that the history in this particular case 
was "Screening for cardiovascular disorders", which does not qualify for reimbursement per CMS guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. The test at issue in this appeal, the 
ultrasound of the abdominal aorta, was requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Based on this information, we decided that Medicare rules for coverage of 
the ultrasound of the abdominal aorta have not been met. Therefore, we decided that the Plan does not have to 
pay for the ultrasound of the abdominal aorta (76706) provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on September 7, 2022, to 
September 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the record attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
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 chiropractic services provided on September 7, 
2022, to September 12, 2022, by an out-of-network (OON) provider.