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

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on September 3, 2022. 
 
  You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that the 
enrollee cut their finger and needed emergency medical service transport to the nearest facility. The Plan 
denied your request. The Plan says the information provided does not support ambulance transport to or from 
an outpatient facility, which is not a covered destination. The Plan also says there was no documented acute, 
urgent, or emergent condition, and van transport or other vehicle may have been an option. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) 
and ground mileage (A0425) provided on September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit (99213) and 
diagnostic x-rays (92134) provided on September 14, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit (99213) and diagnostic x-rays (92134). 
You say that the receptionist at the providers office said there was a $15 copayment. You also say that you 
received a bill for the remaining $25. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $40 
copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye. 
 
You have been asked to pay a $40 copayment for a specialist office visit (99213) and diagnostic x-rays 
(92134). This item/service falls within the Medicare-covered outpatient visit for services to diagnose and/or 
treat a disease or condition of the eye 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 reduce the copayment for a 
specialist office visit (99213) and diagnostic x-rays (92134) provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454-59 billed for date of service 
November 4, 2021. 
 You asked the Plan to pay for the billed services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the service cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 64454 is a column II code to column I code 20611. The medical 
records do not show that code 64454, billed with the -59 modifier, was a distinct procedural service. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 64454-59 billed for date of service November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) provided on September 
14, 2022. 
 
You asked the Plan to pay for a medical eye examination (92014). You say that you were not aware of any pre-
authorization being necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92014) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral 
complete series of x-rays (D0210), and adult prophylaxis (D1110) provided on September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you moved and picked a dentist off of the Plan 
list. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), an intraoral complete series of x-rays (D0210), and adult 
prophylaxis (D1110) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for a new patient (99203) provided on August 
12, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee has not seen the same or 
another provider within the practice before. You also say that the service was billed correctly. The Plan denied 
your request. The Plan says that the claim denied correctly. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the provided documentation 
indicates that the enrollee previously received professional services from this physician within the last three 
years. Based on this information, we decided that Medicare rules for coverage of the outpatient services have 
not been met. Therefore, we decided that the Plan does not have to pay for the office visit for a new patient 
(99203) provided on August 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat radiofrequency ablation (RFA) of the lower 
back at spinal levels L3-4 and L4-5 (64636, 64635). 
 
You asked the Plan to pre-approve the repeat RFA of the lower back. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent 
improvement in the ability to perform previously painful movements and activities of daily living (ADLs) as 
compared to baseline measurement using the same scale. 
 
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 repeat RFA of the lower back. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the member did not 
achieve at least 6 months of 50% pain relief. 
 
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 repeat RFA of the lower back have not been met. Therefore, we decided that the Plan does not have to pre-approve the repeat radiofrequency ablation (RFA) of the lower back at spinal 
levels L3-4 and L4-5 (64636, 64635).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) provided on August 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that after you verified prices at various optics within 
the Plan network, you decided to take the script and buy the frames for your glasses with this provider. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for frames (V2020) provided on August 12, 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 assistance walking and need intensive 
rehab to recover. The Plan denied your request. The Plan says the request is not medically necessary, the 
services you need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of 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 IRF admission and services.
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 the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting, further delay in care will have a detrimental effect on the enrollee's safety, 
ability to fully recover, be discharged to a community setting and stay in that community setting, averting 
unplanned readmission. The Plan denied your request. The Plan says the enrollees medical condition is stable. 
The medical complexity of care is low, and the notes do not show a need for close care from a physician 
specializing in the field or Physical Medicine and Rehabilitation. 
 
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 the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week 
of rehabilitative services with regular physician evaluation. The enrollees care needs can be met safely at a 
lower level of 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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary to optimize the 
enrollee's level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary. 
 
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 while the enrollee may have a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services.  Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on August 1, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the provider did not notify you about the 
frequency limitation. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) 
provided on August 1, 2022.  
 
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. 
 
Your complaint that the dental hygienist was unprofessional is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) low back with 
sedation. 
 
You asked the Plan to pre-approve an epidural steroid injection (ESI) low back with sedation. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale* for 
at least three months. 
 
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 an epidural steroid injection (ESI) low 
back with sedation. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the member did not achieve at least three months of 50% pain relief. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection (ESI) low back with sedation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) low back 
with sedation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208). 
 
You asked the Plan to pre-approve insertion of new or replacement of permanent pacemaker. You say that 
medical records were submitted with the appeal request to support the medial necessity for the requested 
service. The Plan denied your request. The Plan says based upon the clinical notes reviewed, the enrollee does 
not meet medical necessity guidelines. Atrial fibrillation is listed in the documentation and the review of the 
records shows anticipated ablation but not indications that would meet NCD criteria. 
 
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 insertion of new or replacement of 
permanent pacemaker. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and 
necessity of implantation of a pacemaker in an enrollee with atrial fibrillation whose rate has not been 
medically controlled. The plan is to proceed with pacemaker implant and AV node ablation; however, maximal 
AV nodal blockade has not been achieved. No significant bradycardia has been documented that would 
contraindicate further AV blockade. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac pacemaker in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of new or replacement of permanent pacemaker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an insertion of new or replacement of 
permanent pacemaker with transvenous electrode(s); atrial and ventricular (33208).
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 you are medically stable and do not need physician's supervision 3 times a week in an 
IRF. At the current level of function, you do not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. While you may benefit 
from continued physical therapy, and occupational therapy, your rehabilitation needs can be safely provided in 
a lower intensity and alternate setting. 
 
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.