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

 
We decided that the Plan does not have to pre-approve 3D rendering with interpretation and report of an 
approved echocardiogram. 
 
You asked the Plan to pre-approve the 3D rending of the approved echocardiogram. You say that this imaging 
is medically necessary. The Plan denied your request. The Plan says there is no evidence that 3D rendering is 
required in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that to support the need for 3D rendering of an 
imaging study, the referring physician must generate an appropriate written request indicating the clinical need 
for the additional 3D imaging. 
 
We looked at the file and Medicare rules. In this case, the file contains no written report indicating the clinical 
need for 3D imaging versus standard 2D imaging. We asked the Plan to contact the referring physician to 
obtain such a statement but none was submitted to the Plan. Based on this information, we decided that 
Medicare rules for coverage of the 3D rending of the approved echocardiogram have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 3D rendering with interpretation and report of an 
approved echocardiogram.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 7, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim did not include 
the required DEX Z-Code. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
required claim information must be submitted.  
 
We looked at the file and Medicare rules. The genetic testing in this case was not billed with the required DEX 
Z-Code for payment to be considered. Based on this information, we decided that Medicare rules for coverage 
of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were not authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the podiatry services provided on February 16, 2022, by an out-of-network 
(OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on August 30, 2021. 
 
You asked the Plan to pay for the ER visit. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
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. Therefore, 
we decided that the Plan does not have to pay for the ER visit provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on January 27, 2022, to April 16, 2022. 
 
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 procedure code A4256 is not supported. 
 
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 A4256 is normal, low and high calibrator solution / chips. 
 
We find that CPT code A4256 is not supported in the medical record. Specifically, there is no documentation 
of quantity of the supplies ordered. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the supplies 
rendered on January 27, 2022, to April 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2021, billed with 
codes 81206, 81275, 81276, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 3, 2021, billed with codes 81206, 81275, 81276, and 81301.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria has not been met. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for tib-fib fracture and knee hemarthrosis after an injury. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power seat lift provided on March 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for power seat lift. You say that you did not know you needed prior authorization. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 power seat lift at issue in this appeal. The Plan did not pre-approve the 
power seat lift at issue. We found no exception that would require the Plan to pay for the power seat lift. 
Therefore, we decided that the Plan does not have to pay for power seat lift provided on March 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment (D6950). 
 
You asked the Plan to pre-approve a precision attachment. You say that you need precision attachments for 
your denture partial to the implant that you already have. The Plan denied your request. The Plan says this 
service is not covered under your plan. 
 
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 pre-approve a 
precision attachment (D6950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on March 1, 2022. 
 
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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 16, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray rendered on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4215 and A4556 billed on January 15, 2021. 
 
You asked the Plan to pay for procedure codes A4215 and A4556. You say that there were no in-network 
neuromonitoring neurologists in your area and the services were medically necessary. You say that the claim 
should be reviewed, and the balance provided. The Plan denied your request. The Plan says procedure codes 
A4215 and A4556 have a bundled status and cannot be separately paid. The Plan also says the remaining 
denied codes were reprocessed due to a corrected claim being submitted. 
 
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 A4215 is needle, sterile, any size, each. The CPT Code 
Manual definition of code A4556 is electrodes, (e.g., apnea monitor), per pair  
 
We find that CPT codes A4215 and A4556 are not supported in the medical record. Specifically, procedure 
codes A4215 and A4556 are not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure codes A4215 and A4556 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes A4215 and A4556 billed on January 15, 2021.
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 October 23, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
transported to the hospital, and this bill should be paid. The Plan denied your request. The Plan says you were 
evaluated and treated, but not transported to a facility on this date of 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 October 23, 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 October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on December 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that the drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the testing is not separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by the code at issue is considered 
specimen validity testing, which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the validity testing provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 24, 2022, 
by an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services received by the 
enrollee were medically necessary. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 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 subsequent nursing facility care provided on 
March 24, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for infusion services provided to the enrollee on August 25, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in this case. The plan has not given 
any specific reasons why the codes were not used appropriately in this case. The plan's denial reason is vague 
and cannot be verified. Therefore, we decided that the Plan has to pay for infusion services provided to the 
enrollee on August 25, 2020.  
 
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 more for the crown - porcelain fused to high noble metal 
(D2750) provided March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you should have 20% coinsurance for this 
service. The Plan denied your request. The Plan says you are responsible for 50% coinsurance plus any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
You have been asked to pay 50% coinsurance plus the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for the crown - porcelain 
fused to high noble metal (D2750) provided March 2, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 ventilator system. 
 
You asked the Plan to pre-approve a Life2000 system. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 
have not been met. 
 
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 a Life2000 system. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has a diagnosis of COPD and partially paralyzed hemidiaphragm, but pulmonary function tests 
show no restrictive disease, and there is no evidence of neuromuscular disease. There is no arterial blood gas 
(ABG) test done as an outpatient while stable showing chronic carbon dioxide retention. The Life2000 system is not a true ventilator because it cannot provide full ventilatory support, and there is insufficient evidence that 
it is beneficial in the treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Life2000 system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Life2000 ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopath services provided from February 9, 2022, to 
February 11, 2022 
 
You asked the Plan to pay for naturopath services. The Plan denied your request. The Plan says Medicare 
guidelines lists Naturopaths as non-physicians not permitted to enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopath services provided from February 9, 2022, to February 11, 2022
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation - new or established patient (D0150) 
and intraoral - complete series of radiographic images (D0210) provided March 29, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you 
needed to find a good dentist who accepted your insurance. The Plan denied your request. The Plan says that 
you have exceeded the frequency limit for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, no evidence of previous service covered was provided. Without 
documentation of the previous services, we are unable to verify that the Plans frequency limits have been 
exceeded. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation - new or 
established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided March 29, 
2022.  
 
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 moderate sedation services rendered on February 5, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on February 5, 2022.