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

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 29, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that by the time the ambulance arrived, you were 
symptom free. You say that the ambulance would not take you to the hospital you requested. You also say that 
you feel you should not be liable for this bill. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on January 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (37224 and 37230) provided from 
November 16, 2021, to November 17, 2021. 
 
You asked the Plan to pay for codes 37224 and 37230. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file, the Plan's contract, and Medicare rules. In this case, codes 37224 and 37230 have a 
bilateral indicator code of "1," indicating that an anatomical modifier is necessary. The file shows that the 
claim was not billed with the appropriate bilateral modifier. Therefore, we decided that the Plan does not have 
to pay for the surgical services (37224 and 37230) provided from November 16, 2021, to November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, and 81321 
provided on February 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, if a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was submitted for the panel provided Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, and 
81321 provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seat lift mechanism (E0627) DME delivery, set up, and/or 
dispensing service component (A9901) sales tax (S9999) purchased December 6, 2021. 
 
You asked the Plan to pay for the seat lift mechanism. You say that at the time of purchase you were unaware 
that the insurance would not cover the cost. You did not realize that there was a particular vendor that you 
needed to utilize. The Plan denied your request. The Plan says the provider is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for seat lift mechanism (E0627) DME 
delivery, set up, and/or dispensing service component (A9901) sales tax (S9999) purchased December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PCP services. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this provider is not contracting as a primary care provider; therefore, the enrollee cannot 
select this provider to be the enrollee's PCP. The Plan states they did approve six (6) visits with this provider 
for medical necessity. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
This provider is not contracting as a primary care provider; therefore, the enrollee cannot select this provider to 
be the enrollee's PCP. Therefore, we decided that the Plan does not have to pre-approve PCP services.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the discharge date. We decided that the Plan does not 
have to waive the copayment for the remaining days.  
  You asked the Plan to waive the copayment for the discharge day. You say that you have been incorrectly 
billed and the claim has been processed incorrectly. You say that the bill should be adjusted to reflect the 
correct copayment. The Plan says that the copayment applied is correct. 
 
We decided that the Plan has to waive the copayment for the discharge date.  
 
The records show the Plan charged a copayment for 18 SNF days, which included the discharge date. The 
copayment does not apply to the discharge date for inpatient services. Therefore, we decided that the Plan has 
to waive the copayment for the discharge date and reduce the total cost from $3,096 to $2,924.  
 
Dates of Service SNF Days Number of Days Copayment Member Liability 
September 24, 2021- 
September 30, 2021 
Days 1-7 7 Days $0/day $0 
October 1, 2021-
October 13, 2021 
Days 8-20 13 Days $0/day $0 
October 14, 2021-
October 31, 2021 
Days 21-37 17 Days $172/day $2,924 
 
We also decided that the Plan does not have to waive the copayment for the remaining days. 
 
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 $172 
copayment per day for days 21 through 100. Therefore, we decided that the Plan does not have to waive the 
copayment for the remaining days. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for respiratory therapy care (99503) provided 
on August 7, 2020. 
 
You asked the Plan to pay for the home visit for respiratory therapy care (99503). You say that you have 
attached proof of timely filing and the medical records required to reprocess the denied claim. The Plan denied 
your request. The Plan says bundled services are 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 99503 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99503 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home visit for respiratory therapy care (99503) have not been met. Therefore, we decided that 
the Plan does not have to pay for the home visit for respiratory therapy care (99503) provided on August 7, 
2020.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the reinsertion of spinal fixation device (22849). We decided that the 
Plan does not have to pay for allograft for spine surgery (20930).  
 
You asked the Plan to pay for the reinsertion of spinal fixation device (22849) and allograft for spine surgery 
(20930). You say that the multiple procedures rule does not apply for co-surgeons, surgical teams or assistants 
at surgery who perform multiple surgeries on the same patient on the same day. You say that the services were 
medically necessary and should be reimbursed accordingly. The Plan says procedure code 22849 is not 
supported by the medical records submitted. The Plan also says that procedure code 20930 is considered a 
bundle service and not separately payable.  
 
We decided that the Plan has to pay for the reinsertion of spinal fixation device (22849).  
 
The record indicates that the Plan reviewed medical records to support the denial. The Plan has not forwarded 
any clinical information and we are unable to determine if the Plan was justified in denying the billed services. 
It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the reinsertion 
of spinal fixation device (22849).  
 
We also decided that the Plan does not have to pay for allograft for spine surgery (20930). 
 
We find that CPT code 20930 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20930 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of CPT code 20930 have not been met. Therefore, we decided that the Plan does not have to pay for allograft 
for spine surgery (20930). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to 
be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. 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 admission. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 24, 2022 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
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 admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) and endodontic therapy (D3330), 
provided by a participating provider on February 17, 2022. 
 
You asked the Plan to pay for a core build-up and endodontic therapy. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
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 a core 
build-up (D2950) and endodontic therapy (D3330), provided by a participating provider on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve these services. You say that you are unable to reach your bedroom without 
excessive effort. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
requested knee exceeds your needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications. 
 
The file shows that a level 3 microprocessor knee was requested as identified by codes L5856, L5828, L5848, 
L5845, and L585. 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 requested 
services. Our physician reviewer found that you have an above knee amputation. The clinical records show that 
you would require an advance microprocessor due to mobility requirements. You also are documented to have 
neuropathy and would not have sensation required for a mechanical knee. Therefore, the microprocessor knee 
is medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a microprocessor knee.  
 
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 a limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on August 26, 2021, crowns (D2740) and core build up (D2950) on tooth #'s 13 and 19 
provided on August 31, 2021, and a periapical x-ray provided on September 20, 2021. 
 
You asked the Plan to pay for an evaluation, x-rays, crowns, and core build up. You say that you were not 
aware the provider was out-of-network. The Plan denied your request. The Plan says a limited oral evaluation, 
periapical x-ray, and a crown are not covered when seen by an out-of-network provider. The Plan also says that 
core build up is not covered by your Plans supplemental dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, a limited oral evaluation, periapical x-ray, and a crown are not 
among those covered under this benefit when received by an out-of-network provider. Core build up is not 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and periapical x-ray (D0220) provided on August 26, 2021, crowns (D2740) and core build 
up (D2950) on tooth #'s 13 and 19 provided on August 31, 2021, and a periapical x-ray provided on September 
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. You say 
that you were not aware they were out-of-network until after the procedure. The Plan denied your request. The 
Plan says services provided by an out-of-network provider 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 Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 29, 2021. 
 
You asked the Plan to pay for an evaluation. You say that the provider was in-network and should have been 
more aware before the procedure was done. The Plan denied your request. The Plan says this service is covered 
by the Plan's dental benefits; however, your benefit for one procedure every three years has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one 
comprehensive oral evaluation (D0150) every three years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation provided on January 12, 2021; therefore, the benefit for a comprehensive oral 
evaluation has been exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right tributary vein phlebectomy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has ongoing functional 
limitations. The Plan denied your request. The Plan says saphenous reflux is not present or already successfully 
eliminated. 
 The Plan follows Medicare rules. Medicare rules say that varicose vein treatments are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that in this case, the saphenous reflux has not yet been treated so there has not been an 
opportunity to reevaluate the enrollee for the need of phlebectomy.  A rationale for this position is that many 
will experience relief of their symptoms with saphenous reflux treatment alone, and the additional phlebectomy 
might not be necessary. Therefore, the requested service is not medically reasonable at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right tributary vein phlebectomy services.