Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have a 
diagnosis of COPD, although there are no pulmonary function tests for confirmation. You have obstructive 
sleep apnea and obesity hypoventilation syndrome. You may benefit from use of bilevel positive airway pressure (BiPAP) at night as certain BiPAP devices can provide the AVAPS mode of support.  Medicare does 
not cover a ventilator used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 

 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of November 12, 2021, forward and could have been treated in a lesser restrictive 
setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were 
not showing any aggressive behaviors. You were being cooperative and compliant as you awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown repair (D2980) provided June 22, 2021. 
 
You asked the Plan to pay for the crown repair. You say that the repair was medically necessary and should be 
covered. The Plan denied your request. The Plan says this service is not covered under your dental benefit. 
 
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 pay for a crown 
repair (D2980) provided June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and limited oral 
evaluation - problem focused (D0140) provided May 27, 2021. 
 
You asked the Plan to pay for the intraoral x-ray, tooth extraction and limited oral exam. You say that you 
needed your teeth pulled right away. The Plan denied your request. The Plan says these services are not 
covered under your 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 pay for the intraoral - periapical first radiographic image (D0220), extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), and limited oral evaluation - problem focused (D0140) provided May 27, 
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided April 26, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for cardiovascular risk 
assessment screening panels.  
 
We looked at the file and Medicare rules. The service at issue is a cardiovascular risk assessment panel. This 
service is non-covered. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) 
provided April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on May 21, 
2021. 
 
You asked the Plan to pay for code 97010. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 97010 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99325) rendered by the 
out-of-network (OON) provider on May 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit (99325) rendered by the out-of-network (OON) 
provider on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that the charges should be considered payable. 
The Plan denied your request. The Plan says no separate payment is made. 
 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 the rules. We find that CPT code 99140 is a bundled code. When these services are 
covered, payment for them is subsumed by the payment for the services to which they are incident. We find 
that CPT code 00731 has no relative value units or payment amounts. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services provided on April 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
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 reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective; 
you received oral medications. You had stable vital signs. Regarding rehabilitation services, you received 
physical therapy (PT) and occupational therapy (OT) in the acute hospital. You were at stand by 
assist/supervision level with functional mobility including gait to 120 feet with no assistive device. You 
required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. 
There are identifiable skilled therapy service needs. 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray provided on July 8, 2021 and the post and 
core in addition to crown provided on July 12, 2021. 
 
You asked the Plan to pay for the intraoral x-ray and post and core in addition to crown. You say that you were 
told this provider is in-network and you cannot afford this bill. The Plan denied your request. The Plan says 
that claim reprocessed toward your in-network benefits. The Plan also says that the intraoral x-ray and post and 
core are the only services that remain denied as non-covered 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, you also have a maximum benefit of 
one intraoral x-ray per calendar year. The Plan paid for the intraoral x-ray provided on March 1, 2021, which 
exhausted your benefit. The post and core in addition to crown remain denied as a non-covered benefit. 
Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on July 8, 2021 and 
the post and core in addition to crown provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right inguinal hernia repair surgery to be provided at an 
acute care hospital. 
 
You asked the Plan to pre-approve surgery services at an acute care hospital. You say that it is medically 
necessary for this surgery to be provided at an acute care hospital. The Plan denied your request. The Plan says 
there is no medical need for the surgery services to be provided at an acute care hospital in this case. 
 
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 surgery services at an acute care 
hospital. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found The review indicates that the enrollee has a history of 
hypertension and no other chronic illnesses listed; Hernia repair is outpatient for most patients unless there are 
significant underlying medical problems which you do not have listed. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary. Specifically, there is not a 
medical need for the surgery services to be performed at the acute care hospital over the Plan's recommended 
Ambulatory Surgery Center.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery services at an acute care hospital have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right inguinal hernia repair surgery to be provided at an 
acute care hospital.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiograph (99308) provided March 30, 2021. 
 
You asked the Plan to pay for the echocardiograph. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for separate payment. 
 
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 find that CPT code 99308 is not supported in the medical record. Specifically, the record shows the 
enrollee was a skilled nursing facility inpatient at the time services were rendered. The billed code is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the 
echocardiograph have not been met. Therefore, we decided that the Plan does not have to pay for an 
echocardiograph (99308) provided March 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on 
January 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this ambulance service 
was not needed because your husband could have transported you. The Plan denied your request. The Plan says 
you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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 ambulance services you 
received on January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140, D7210) and immediate dentures 
(D5140, D5130) provided on January 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that your benefit covered these 
services, and you were not informed that out-of-network care was not covered or that this provider was not in-
network. The Plan denied your request. The Plan says this provider is not part of the Plan's specified dental 
network. Out-of-network dental care is 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 Plan can cover eligible 
dental services when they are received from an in-network provider. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the extractions (D7140, D7210) and immediate dentures (D5140, D5130) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 53899 provided on May 10, 
2021. 
 
You asked the Plan to pay for the medical services. You say that the documentation provided supports the 
services as they were billed, The Plan denied your request. The Plan says the medical records do not support 
the services as billed. 
 
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 53899 is unlisted procedure, urinary system. 
 
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 medical services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found when reporting an unlisted 
procedure, documentation to support the need for an unlisted code should be appended with documentation for 
billing. Documentation did not include reason for unlisted code. Documentation supports a cystourethroscopy, 
with ureteral catheterization, with or without irrigation. There is a more appropriate code to report for this 
service. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded as 53899 provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on May 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that all services have been billed under the 
guidelines. The Plan denied your request. The Plan says the claim denied correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The file shows that the services at issue were billed with a GT modifier. 
The records do not indicate the services were billed by a critical access hospital. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the telehealth services provided on May 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded as 70450 
provided on July 8, 2021. 
 
You asked the Plan to pay for the CT scan. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says the claim has denied correctly based on Medicare 
rules. 
 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 70450 
is a column II code to column I code 70498. 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 coded as 70450 provided on 
July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Gadoxetate Disodium injection provided 
on June 14, 2021. 
 
You asked the Plan to waive the coinsurance for a Gadoxetate Disodium injection. You say that you should not 
be charged for this because your benefits say that you do not owe anything for radiology services. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
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 20% coinsurance for medical supplies. 
 
You received a Gadoxetate Disodium injection on June 14, 2021. This is considered imaging supplies. 
Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is 
$147.40 and 20% of that is $29.48.   
 
You have been asked to pay the total coinsurance amount of $29.48 for a Gadoxetate Disodium injection. A 
Gadoxetate Disodium injection 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 coinsurance for a Gadoxetate Disodium 
injection provided on June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on April 4, 2021. 
 
You asked the Plan to pay for the ambulance response without transport. You say that the enrollee fell, and the 
ambulance response was necessary. Once evaluated, the enrollee declined transport to the emergency room 
because it was found that he was not seriously hurt on inspection. You are surprised you are responsible for the 
full bill. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. Without 
transport, 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 April 4, 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 without 
transport (A0998) provided on April 4, 2021.