Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facility charges for the dental surgery procedures (41899).
You asked the Plan to pre-approve the facility charges. You say that you are requesting an authorization for the facility, not the extractions. The Plan denied your request. The Plan says since extractions are not covered, facility fees and anesthesia fees are not covered.
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.
Medicare does not have a benefit for outpatient hospital care related to non-Medicare covered dental services.
Therefore, we decided that the Plan does not have to pre-approve the facility charges for the dental surgery
procedures (41899).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads,
interpretation and report only (93010) provided March 14, 2021.
You asked the Plan to pay for the routine ECG. You say that you are attaching the medical records which
support that 93010 was done three times, on which the Plan has paid twice and denied once. The Plan denied
your request. The Plan says the submitted clinical information does not establish medical necessity for repeat
EKG within the same 24-hour period.
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 pay for the routine ECG. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the provided records showed the enrollee had either supraventricular tachycardia or sinus
tachycardia on testing, and no other clinical information was provided to help support why the enrollee
required 3 ECG's. Therefore, without sufficient support made, this request for ECG will be considered not
medically necessary based on the provided documentation.
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 routine ECG have not been met. Therefore, we decided that the Plan does
not have to pay for electrocardiogram, routine ECG with at least 12-leads, interpretation and report only
(93010) provided March 14, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on March 19, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a
covered ambulance destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says
that the requested ambulance transportation was not medically reasonable and necessary. Our physician
reviewer found that the documentation does not support that other means of transport (such as stretcher van)
were contraindicated for this enrollee on March 19, 2021. The documentation does not support that the enrollee
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped
ambulance can provide for safe transport. She was stable and received no treatment during transport. The
documentation does not support that the ambulance transport was medically reasonable and necessary for the
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance transportation provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan eye drops.
You asked the Plan to pre-approve Zioptan. The Plan denied your request. The Plan says this medication is not eligible for coverage under the Part B 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 requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan eye drops.
Benefits for Zioptan 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 pre-approve 33 additional routine transportation trips.
You asked the Plan to pre-approve 33 additional routine transportation trips. You say that these trips are medically necessary. The Plan denied your request. The Plan says the benefit for routine transportation has been exhausted.
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 Plan's coverage rules apply in this case. The Plan covers a maximum of 100 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 33 additional routine transportation trips
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0426, A0425)
provided on April 30, 2021.
You asked the Plan to pay for non-emergency ambulance transportation. You say that the claim was denied,
and you want the Plan to review it. The Plan denied your request. The Plan says the enrollee has a different
primary insurance, and the claim needs to be summitted through them.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you
to submit to the primary insurer for payment. As the secondary insurer, the Plan cannot be held responsible for
non-emergency ambulance transportation until the primary insurer has denied the claim for these services.
Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transportation (A0426,
A0425) provided on April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has suffered for three years and it has impacted qualify of life. The Plan denied your request. The Plan says there are not enough studies to show that this device is safe and effective for back pain.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (17000, 17003, 17110) provided on September
18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more
appropriate code for the services provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
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 services. Our reviewer says that the use of codes 17000,
17003, and 17110 is not supported by the records provided. Our reviewer found that the operative report
documents "Cryotherapy was used to treat more than 14 inflamed seborrheic keratosis lesions." Codes 17000,
17003, and 17110 would be inappropriate to report for this service as a more appropriate code exists.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (17000, 17003, 17110) provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electric stimulation services to aid bone healing. 
 
You asked the Plan to pre-approve the electric stimulation services. You say that this request is medically 
necessary. The Plan denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the electric stimulation services to aid bone 
healing are subject to the criteria listed in the Medicare rules section.

We looked at the file and Medicare rules. In this case, the documentation does not meet Medicare criteria. 
Specifically, the records do not document two X-rays of the bone fracture that demonstrate a lack of healing at 
least 90 days apart. Based on this information, we decided that Medicare rules for coverage of the electric 
stimulation services have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
electric stimulation services to aid bone healing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive dental services.
You asked the Plan to pre-approve the requested services. You say that the enrollee is unable to eat. The Plan
denied your request. The Plan says the services are not covered.
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.
The file shows that guided tissue regeneration, endosteal implants, a reduction of osseous tuberosity, an
osseous graft, and intravenous sedation were requested. Although the Plan offers a dental benefit in excess of
Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we
decided that the Plan does not have to pre-approve comprehensive dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shock absorption pylon (L5988). 
 
You asked the Plan to pre-approve the shock absorption pylon. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requested shock absorption pylon exceeds the member's needs. 
 
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 shock absorption pylon. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal that the patient will be involved with 
high impact activities. The requested pylon exceeds the patient's medical needs. 

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 shock absorption pylon have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the shock absorption pylon (L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99232) provided on March 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The documentation provided does not contain medical records for March 5, 2021. Without records for the date of service in question, it cannot be confirmed that Medicare coverage criteria have been met. 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 the services (99232) provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services provided on November 29, 2019.
You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the therapeutic activities services was not filed until May 24, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the therapeutic activities services provided on November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound dressings.
You asked the Plan to pre-approve the requested services. You say that you need dressings to treat your wounds. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that surgical dressings are only covered under certain medical indications.
The file shows that Acticoat wound dressings were requested. We looked at the file and the rules. The record does not show that you have a qualifying wound. This means that you do not have a medical condition for which the wound dressings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve wound dressings.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31237 provided on May 27, 2021.
You asked the Plan to pay for the nasal/sinus endoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 31237 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 nasal/sinus endoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31237 provided on May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional mileage for routine transportation.
You asked the Plan to pre-approve the additional mileage for routine transportation. You say that you need transportation to a for a medically necessary appointment. The Plan denied your request. The Plan says the service is a covered benefit, but the trip exceeds limits set in the subscriber agreement.
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 Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. In this case you are requesting transport to
an appointment for a distance greater than the Plan's 50-mile limit. Based on this information, we decided that
the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan
does not have to pre-approve the additional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluations (D0140),
panoramic x-rays (D0330), and occlusal orthotic device (D7880) provided from March 30, 2021, to April 26,
2021.
You asked the Plan to pay for the problem focused limited oral evaluations, panoramic x-rays, and occlusal
orthotic device. You say that you contacted the Plan on March 30, 2021 and were advised that
temporomandibular joint (TMJ) services were covered under your medical plan. You also say that the Plan is
billing these services under dental codes but has to be billed under medical codes. The Plan denied your
request. The Plan says the requested services are purely dental in nature and are unrelated to the limited clinical
indications. The Plan also says that the clinical documentation does not support evidence of clinically
significant masticatory impairment with loss of function.
Medicare generally does not cover dental services. The Plan follows the same rule. The rules also 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.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. The records show that the Plan made several attempts to obtain medical records from the
provider, but no records were provided. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluations (D0140), panoramic x-rays (D0330), and occlusal orthotic device
(D7880) provided from March 30, 2021, to April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 177 provided from September 15, 2019, to September 23, 2019.
You asked the Plan to pay for the inpatient hospital services billed with DRG 177. You say that you disagree with the denial made for a DRG change from 177 to 194. The Plan denied your request. The Plan says DRG 177 is not supported as the diagnoses of pneumonia due to other Gram-negative bacteria and acute and chronic respiratory failure with hypoxia are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code J15.6, pneumonia due to other Gram-negative bacteria and diagnosis code, J96.21, acute and chronic respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services billed with DRG 177. Our reviewer says that DRG 177 is not supported. Our physician reviewer found the record indicates that the enrollee was admitted with hypoxia and had a positive Coronavirus screen. Our reviewer also found that the record does not support the statement of the presence of Gram-negative organisms as the etiology of the pneumonia. The elements of the coverage criteria are not satisfied, and therefore the requested service cannot be recommended as billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 177 provided from September 15, 2019, to September 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, chest (71046)
provided June 28, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that the chest x-ray was ordered
as part of pre-op testing necessary for the cataract surgery. The EKG and blood work were covered, and this
should be as well. The Plan denied your request. The Plan says the claim was processed with the correct cost
share applied per the Evidence of Coverage.
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 $50
copay when x-rays are performed in an independent diagnostic testing facility.
You have been asked to pay $26.34 for the diagnostic service. Since the Allowed amount was less than the
copay amount, you are responsible for the lesser amount. The diagnostic service falls within the Outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the radiologic examination, chest (71046) provided June 28, 2021.