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

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan services coded 70480 
provided on January 15, 2022. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed 
with this code as required by Medicare billing regulations. 
 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 70480 
is a column II code to column I code 70450. 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 the computed tomography (CT) scan services coded 70480 
provided on January 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of hematoma, seroma or fluid 
collection (10140) provided on December 15, 2021. 
 
You asked the Plan to pay for the incision and drainage of hematoma, seroma or fluid collection. You say that 
you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan 
says this claim has been billed with an inappropriate modifier. 
 
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 looked at the file and Medicare rules. In this case, this code has been billed with modifier 78 indicating it as 
an unplanned return to the operating room by the same physician following initial procedure for a related 
procedure during the postoperative period. However, there is no indication what the initial procedure was in 
this case that would require modifier 78. Based on this information, we decided that Medicare rules for 
coverage of the incision and drainage of hematoma, seroma or fluid collection have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of hematoma, seroma or fluid 
collection (10140) provided on December 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the SNF is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the SNF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as on an intermittent outpatient basis, in a long-term 
care facility, or at the home with home health care services.  
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. The enrollee does not require skilled nursing or therapy services 
on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oxygen equipment. 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the item is medically necessary. The 
Plan denied your request. The Plan says only rented oxygen systems are eligible for coverage. Purchased 
oxygen equipment is statutorily non-covered. 
 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen systems are eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pre-
approve the oxygen equipment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 30, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says this specific genetic test is not a 
Medicare-covered benefit. 
 
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 the genetic testing services provided 
on November 30, 2021, have been met. Specifically, no documentation was provided that indicates the testing 
was specifically ordered by the enrollees provider. Therefore, we decided that the Plan does not have to pay 
for the genetic testing services provided on November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that you need to receive skilled nursing care in order 
to strengthen your muscle mass and increase your mobility. You state you are back home, and your legally 
blind husband is assisting you with exercise, showering, and walking with a walker. The Plan denied your 
request. The Plan says authorization denied because the SNF care is not medically necessary, and your needs can be met at a lower level of care such as home with home health, residential care, or home with close follow-
up with their doctor. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are no identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. You do not require skilled nursing or therapy services on a daily 
basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CxBladder genetic testing (0013M) provided on 
November 12, 2021. 
 
You asked the Plan to pre-approve CxBladder genetic testing. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says this testing is not covered 
per Medicare coverage rules. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for 
Current Procedural Terminology (CPT) codes 0012M and 0013M for CxBladder genetic testing. Based on this 
information, we decided that Medicare rules for coverage of CxBladder genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve CxBladder genetic testing (0013M) provided 
on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a night guard. 
 
You asked the Plan to pre-approve a night guard. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a night guard is not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested night guard is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a night 
guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoe lift (L3334). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. 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 a shoe lift (L3334).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) provided on February 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you 
would like this claim reprocessed based on the medical necessity. The Plan denied your request. The Plan says 
prior authorization was not obtained for these services rendered by an OON 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 the psychiatric diagnostic evaluation with medical 
services (90792) provided on February 24, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that the SNF is medically necessary. You state that 
due to the documented physical impairments and associated functional deficits, without skilled therapeutic 
intervention, the enrollee is at risk for falls and declining in function and mobility. The Plan denied your 
request. The Plan says authorization because the SNF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. The enrollee does not require skilled nursing or therapy services 
on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on January 13, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that even though your dentist is out-of-network, 
you believe this expense should be reimbursed by the Plan. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body: endosteal implant (D6010) provided on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the echocardiography, transthoracic, complete, with 
spect doppler echo and color flow doppler (TTE) (93306). 
 
You asked the Plan to pre-approve the TTE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 TTE. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are not any apparent symptoms reflective of a significant cardiac abnormality. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the echocardiography, transthoracic, complete, with spect doppler echo and color flow doppler 
(TTE) (93306).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 24, 
2021, to December 25, 2021.  
You asked the Plan to pay for the self-administered drugs. You say that you needed to drink the Peg-electrolyte 
4000 before your procedure. You say that there were other medications administered during your stay. You 
also say that you had no control over what you were given. 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 from December 24, 2021, to December 25, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre Continuous Glucose Monitor. 
 
You asked the Plan to pre-approve the Freestyle Libre Continuous Glucose Monitor. You say that the item is 
medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for a Continuous 
Glucose Monitor. 
 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Freestyle Libre Continuous Glucose Monitor.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the flex walk system (L5981) and vertical shock reducing pylon 
feature (L5988). 
 
You asked the Plan to pre-approve the prosthesis additions. You say that the items are medically necessary. 
The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the medically necessary items are 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 prosthesis additions. Our reviewer 
says that the items are medically necessary. Our physician reviewer found the orthopaedic surgeon corroborates 
the K3 abilities of the patient and signature on prescription. 
 
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 prosthesis additions have been met. Therefore, we decided that the Plan has 
to pre-approve the flex walk system (L5981) and vertical shock reducing pylon feature (L5988).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens (V2100), eye exams (92002 and 92014), and frames 
(V2020) provided on July 1, 2021 by an out-of-network (OON) provider.  
You asked the Plan to pay for the lens, eye exams, and frames. You say that you have vision coverage, and 
these services should be paid. The Plan denied your request. The Plan says these services were rendered by a 
non-participating provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows you received these services from an 
OON provider. Based on this information, we decided that the Plan's rules for coverage of the lens, eye exams, 
and frames have not been met. Therefore, we decided that the Plan does not have to pay for the lens (V2100), 
eye exams (92002 and 92014), and frames (V2020) provided on July 1, 2021 by an out-of-network (OON) 
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 November 6, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
told that you were covered for out of state emergencies. You also say that you should not have to pay this claim 
out of pocket. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport 
benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare covered services. The Plan 
also says that the ambulance was called, and you were not transported to an emergency facility. 
 
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 6, 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 November 6, 2021.