Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (27280) and inpatient hospital admission. 
 
You asked the Plan to pre-approve arthrodesis and inpatient hospital admission. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 arthrodesis and inpatient hospital 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding any 
follow-up examinations to demonstrate a return of the pain (along with objective findings corroborating the 
pathology). Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures. He has trialed 2 sacroiliac joint injections; 
however, no other conservative treatments have been tried. Multiple other plausible pain generators including 
at the lumbosacral spine are evident. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis and inpatient hospital admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthrodesis (27280) and inpatient hospital admission.
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 IRF care is medically necessary and the enrollee's 
ability to regain maximum function could be seriously jeopardized if IRF care is not approved. The Plan denied 
your request. The Plan says the enrollee is currently unstable for discharge from the inpatient hospital setting 
and ongoing skilled care can be provided in an alternative setting. 
 
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 has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 11, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not want to go to the hospital to add another bill to yourself or your insurance. The Plan denied your request. 
The Plan says this claim processed correctly. 
 
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 September 11, 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 September 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5257) provided on June 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware of the network status for this 
service, as it was not provided to you. The Plan denied your request. The Plan says the provider that performed 
these services is not in-network. The Plan also says that prior authorization was not obtained by the provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are rendered by a participating provider.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aids (V5257) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
January 11, 2022.  
You asked the Plan to pay for the determination of refractive state. You say that you would like your benefits to 
be continued through the state and Medicare plan. The Plan denied your request. The Plan says Medicare does 
not cover routine eye exams (refraction) and you do not have any additional vision benefits that would allow 
for payment of this service. 
 
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. Original Medicare does not cover eye refractions. 
 
We looked at the file and the Plan's rules. You received a refraction which is not covered under your plan. 
Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state 
have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive 
state (92015) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incision biopsy of oral tissue (D7286) and the 
inhalation of nitrous oxide (D9230) to be provided by a network provider. 
 
You asked the Plan to pre-approve the incision biopsy of oral tissue (D7286) and the inhalation of nitrous oxide 
(D9230). You say that the enrollee has a lesion on the right lateral tongue and the plan is to do a biopsy.  The 
Plan denied your request. The Plan says the incision biopsy of oral tissue (D7286) is not a covered service, and 
the inhalation of nitrous oxide (D9230) is denied because the service can only be allowed if the other service is 
approved. 
 
 
 
 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 incision biopsy of oral tissue 
(D7286) is not among those covered under this benefit and the inhalation of nitrous oxide (D9230 can only be 
allowed if the other service is approved. 
 
Therefore, we decided that the Plan does not have to pre-approve the incision biopsy of oral tissue (D7286) and 
the inhalation of nitrous oxide (D9230) to be provided by a network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery for your Inogen portable oxygen 
concentrator (POC). 
 
You asked the Plan to pre-approve an extra battery for your Inogen portable oxygen concentrator (POC).. You 
say that the item is medically necessary. The Plan denied your request. The Plan says Medicare does not 
provide coverage for POC batteries as the item itself, the POC, can be recharged. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra battery for your Inogen portable oxygen concentrator (POC). have not been met. 
Specifically, when a POC is authorized, it includes the device itself, and an integrated battery or beneficiary-
replaceable battery. Medicare does not cover an extra set of batteries. Therefore, we decided that the Plan does 
not have to pre-approve an extra battery for your Inogen portable oxygen concentrator (POC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine periodic exam (D0120), bitewing x-ray (D0274), 
and the cleaning (D1110) provided by a network provider on December 17, 2021. 
 
You asked the Plan to pay for the routine periodic exam (D0120), bitewing x-ray (D0274), and the cleaning 
(D1110). You say that the dental rider does not indicate the routine services would be included in the $1,500 
annual limit. The Plan denied your request. The Plan says the services are covered benefits, but the annual 
benefit maximum of $1,500 has been reached. 
 
 
 
 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 Plan also has an annual maximum 
benefit amount of $1,500. The record shows the Plan paid for services on February 2, 2021, May 14, 2021, and 
June 22, 2021, which exhausted the benefit. Therefore, we decided that the Plan does not have to pay for the 
routine periodic exam (D0120), bitewing x-ray (D0274), and the cleaning (D1110) provided by a network 
provider on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) provided by a network 
provider on January 20, 2022. 
 
You asked the Plan to pay for the comprehensive evaluation (D0150). You say that you have severe toothaches 
due to tooth erosion and you need to replace with a crown instead of tooth restoration. The Plan denied your 
request. The Plan says the service exceeded the frequency limitation in the benefit 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 Plan also has a maximum benefit 
of one comprehensive exam covered every three plan years. The requested service is not covered because the 
Plan paid for comprehensive exam on July 25, 2019, which exhausted your benefit. Therefore, we decided that 
the Plan does not have to pay for the comprehensive exam (D0150) provided by a network provider on January 
20, 2022.
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. The Plan denied your request. The Plan says you do not require a 
coordinated team approach. 
 
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 physician reviewer found 
that you were admitted to the acute hospital with low back spasms. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557) 
provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you thought you 
were getting a free hearing test. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 an $85 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay an $85 copayment for the comprehensive hearing test. the comprehensive hearing 
test 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 comprehensive hearing test (92557) provided on January 
24, 2022.
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 admission. You say that IRF admission is medically necessary so you 
can return home to your spouse. The Plan denied your request. The Plan says IRF admission is not medically 
necessary and your needs can be met at a lower level of care such as in 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 that while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on February 11, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you went through the Plan's hearing aid vendor 
two years ago and you never used the hearing aids because they were not helping you. You also say that the 
hearing aids you received from the OON provider are helping you greatly and you would like a fair return on 
the cost of them. The Plan denied your request. The Plan says you received your hearing aids from a non-
participating provider. The Plan also says that you have no coverage for hearing aids if they are not received 
from a Plan approved hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plans hearing aid vendor for hearing aid services.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met.  
  
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) provided on February 11, 
2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient office visit (99213) provided 
on November 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the deductible for the outpatient office visit. You say that you had a routine eye 
exam on this date of service, and the Plan has covered your routine eye exams in the past. You also say that 
you would like to be reimbursed for this service. The Plan denied your request. The Plan says the $1000 
deductible was not satisfied at the time of service. The Plan also says that according to the medical records and 
confirmation from the providers office, you presented with issues with your vision, and this was not a routine 
exam. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to out-of-network (OON) Vision 
care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the OON Vision care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to OON Vision care. This cost sharing is a contractual obligation that had not been 
met at the time the outpatient office visit was received on November 17, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the outpatient office visit (99213) provided on November 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and 
ground mileage (A0425) provided on November 20, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the transport took place prior to the 
enrollee's hospice enrollment. 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. The hospice 
election is effective the date it is elected and is not time specific. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) provided on 
November 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for breast ultrasound services provided on October 19, 2021. 
 
You asked the Plan to pay for ultrasound. You say that the enrollee had multiple examinations on this date. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan 
already paid for these codes once; therefore, this billing is an exact duplicate. 
 
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 76642-26-LT and -RT is ultrasound, breast, unilateral, 
real time with image documentation, including axilla when performed; limited. 
 
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 ultrasound. Our reviewer says that these codes do not meet 
the criteria for payment. Our reviewer found there are 2 reports of the same examination done on the same date. 
The header on each exam is ultrasound left breast. The description of each report includes technique and 
conclusions of bilateral breasts. While the technique described implies bilateral exams and reimbursement, the 
header of the exam must document the correct exam in order to qualify for reimbursement. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for breast ultrasound services provided on October 19, 2021.
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. The Plan denied your request. The Plan says you are without 
complex rehab needs. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for non-operative management of a pelvic fracture after a fall. 
Your medical problems are stable. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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.