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

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (93010) provided on June 6, 2021. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would 
like reconsideration because this claim was billed correctly. The Plan denied your request. The Plan says 
Z01.810 may only be used as first-listed or primary diagnosis position. 
 
The Plan must follow Medicare rules. Medicare rules say that Z01 may only be reported as the principal/first-
listed diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit and electrocardiogram have not been met. Specifically, diagnosis 
code Z01.810 was not billed as the principal/first listed diagnosis. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit (99285) and electrocardiogram (93010) provided on June 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services, provided on November 30, 2021, to 
December 8, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says Medicare does not cover chiropractic services unless rendered for 
subluxation and there is no documentation indicating subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services, provided on November 30, 2021, to December 8, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee requires skilled physical therapy to 
rehabilitate from deconditioning. The Plan denied your request. The Plan says the enrollee's needs are 
custodial. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer 
found that the enrollee was admitted to the hospital for lower extremity infection with sepsis. He was treated 
medically and eventually had a below the knee amputation. The most recent therapy documentation indicates 
he has had difficulty working with rehab services due to cognitive deficits. He appears to be treated mainly 
with range of motion and strengthening exercises. He does not have any parental medication, complex wound 
care, or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic 
medical problems.  His physical function is at or near his new baseline. Therefore, an admission to a SNF for 
inpatient skilled rehab services is 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the pain in your 
feet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a commode chair (E0163). 
 
You asked the Plan to pay for a commode chair. You say that the item is medically necessary. The Plan denied 
your request. The Plan says no medical records were submitted to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a commode chair (E0163) have been 
met. Medical records were not submitted. Therefore, we decided that the Plan does not have to pay for a 
commode chair (E0163).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) provided on May 5, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee's hospice 
benefit was revoked on the date of service in this case. 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. 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 the initial nursing facility care (99306) provided on May 5, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant, 
providing care in the home; per hour (S9122) provided from February 20, 2021, to March 25, 2021. 
 
You asked the Plan to reimburse you for the home health services. You say that the services should be covered. 
You also say that you were not given vital information by the plan representative that you spoke to. 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. 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 reimburse you for the home health aide or certified nurse assistant, 
providing care in the home; per hour (S9122) provided from February 20, 2021, to March 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were provided at the request of the 
referring provider. You also say that the services should be paid. 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. 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 the laboratory testing provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74181 billed for date of service December 
23, 2021. 
 You asked the Plan to pay for procedure code 74181. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74181 is bundled into payment for 
code 74183. 
 
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 74181 
is a column II code to column I code 74183. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74181 billed for date of service December 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), crown (D2750), and scaling and 
root planing (D4341 x 2) provided from July 26, 2021, to August 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are very unhappy with how the dental 
office handled your appointments and their lack of communication. You also say that you feel you should not 
be responsible for this bill. The Plan denied your request. The Plan says the annual maximum allowance of 
$2,500 has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum allowance has 
been exhausted. The record shows that the Plan paid $321 for services received on July 19, 2021, $2,050, for services received on July 26, 2021, and $129 for services received on August 9, 2021. $321 + $2,050 + $129 = 
$2,500. The Evidence of Coverage clearly states that after the annual maximum s exhausted, any remaining 
charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950), crown (D2750), and scaling and root planing (D4341 x 2) provided from July 26, 2021, to August 9, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services received on August 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that Medicare covers this service. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services received on August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 31, 2020, to November 1, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were very sick. You say that you 
could not possibly tell the doctors to check each drug to make sure that it would be covered. You also say that you feel these drugs should be covered. The Plan denied your request. The Plan says the drugs you received are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B. 
 
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 requested here 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 
provided in an outpatient setting from October 31, 2020, to November 1, 2020.  
 
Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that by the time the provider arrived, you had 
recovered. You say that your vitals being taken. You say that you walked around for evaluation. You also say 
that there were no other treatments administered. The Plan denied your request. The Plan says since there was 
no transport provided, there is no payable 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 November 10, 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, no 
transport, (A0998) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065), and a 
prefabricated abutment (D6056) to be provided by a participating provider. 
 
You asked the Plan to pre-approve an implant supported crown and a prefabricated abutment. You say that this 
was covered in 2021. You say that you do not understand why it is not covered now. The Plan denied your 
request. The Plan says D6065 and D6056 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 Plan's 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 pre-approve an 
implant supported crown (D6065), and a prefabricated abutment (D6056) to be provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of CPT code 21453 provided on January 
15, 2021.  You asked the Plan to pay for the additional unit of CPT code 21453. The Plan denied your request. The Plan 
says one unit of 21453 has been overturned and the additional unit remains denied. 
 
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 21453 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 21453 have not been met. Therefore, we decided that the Plan does not have to pay 
for the additional unit of CPT code 21453 provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a full mouth debridement. You say that you need these services for teeth 
cleaning. The Plan denied your request. The Plan says this service has been correctly denied. 
 
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 a full mouth 
debridement when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. D4355 cannot be provided within 12 months of an oral cleaning. 
Based on this information, we decided that the Plan's rules for coverage of a full mouth debridement have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement (D4355) 
to be provided by a participating provider.
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 October 30, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and needed help getting up. You also say that there was a possibility you would have to be transported to the 
hospital. The Plan denied your request. The Plan says your plan covers ambulance transportation only when 
you are actually transported by ambulance. The Plan also says that since you were not transported by 
ambulance, the service is not covered by your plan. 
 
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 October 30, 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 October 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on May 4, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be paid. 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. 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 the coronavirus testing (U0003, U0005) provided on May 4, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from October 21, 
2021, to November 19, 2021. 
 
You asked the Plan to pay for the home health care services. You say that your company had a staff shortage 
around the time this RAP claim had been generated. You also say that the interim staff's handling of billing 
process resulted in certain errors, and it is evident this missing RAP submission was one of those errors. The 
Plan denied your request. The Plan says the non-contracted provider did not submit the RAP claim for services 
for date of service October 21, 2021, to November 19, 2021 until December 21, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, October 21, 2021. 
 Therefore, we decided that the Plan does not have to pay for the home health care services provided from 
October 21, 2021, to November 19, 2021.