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

 
We decided that the Plan does not have to pre-approve arthroscopic surgery for the fingers. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is not appropriate for this diagnosis, and is not the standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has arthritis of the fingers. Arthroscopy is not medically needed for arthritis of the fingers. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroscopic surgery for the fingers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a physician office visit provided on 
November 3, 2021 
 
You asked the Plan to waive the deductible for a physician office visit. You say that you do not have medical 
coverage. You also say your medical ended in 2019. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $1,000 deductible which applies to out of network physician services.  
 
The Plan approved the office visit, but your deductible applies.  The item or service you asked the Plan to reconsider the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible 
which applies to out of network physician services. This cost sharing is a contractual obligation that had not 
been met at the time a physician office visit was received on November 3, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for a physician office visit provided on November 3, 2021
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance 
transportation (A0429) provided on May 14, 2020. 
 
You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that you 
know this claim was billed outside of the timely filing limits, but you are asking that the claim be reprocessed 
anyway. The Plan denied your request. The Plan says this claim was received on November 23, 2021. The Plan 
also says that this is past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ground mileage and emergency ambulance transportation was not filed 
until November 23, 2021. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ground mileage 
(A0425) and emergency ambulance transportation (A0429) provided on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on July 14, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 76 year old male with dementia who is bed-confined 
who was transported from the hospital to the skilled nursing facility (SNF) via ambulance non-emergently. It 
was noted that multiple staff were required to support this enrollee for transfers. The Glasgow Coma Scale 
(GCS) was 14. The notes show the enrollee as hemodynamically stable and did not describe the reason for 
needing staff for transfers. No treatment was needed during transport. The documentation does not support that 
other means of transport (such as stretcher van) were contraindicated for this enrollee on July 14, 2021. The 
documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport on July 14, 2021. The documentation does not support that the ambulance transport on July 14, 2021 was medically reasonable 
and necessary for the enrollee.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the requested services. You say that you are unable to operate your pump 
without assistance. The Plan denied your request. The Plan says additional services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that home health skilled nursing and aide services were requested. 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 been treated for a wound on your right leg. Your records show that your nurse is not treating your wound 
at this time. You do not require skilled nursing services beyond what was approved by the plan. You have 
caregiver(s) who help with your daily living activities which include bathing, dressing, toileting, grooming, 
cleaning, and meal preparation. The information does not support that a home health aide is reasonable and 
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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 25, 2021, to October 26, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the only medication received during the 
hospital stay were the ones provided by the hospital staff. The Plan denied your request.  The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs 
are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from October 25, 2021, to October 26, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the dental services provided from April 
23, 2021, to November 5, 2021, by an out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the 2021 Benefits at a 
Glance does not indicate that dental services must be provided by an in network provider. You also say that 
you did not have tooth # 19 removed previously, only one of the roots. The Plan denied your request.  The Plan says that dental services you receive out of network may cost more. The Plan also says that the crown 
cannot be paid as there is a claim for the extraction of the same tooth prior to the date of service of the crown. 
 
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, services you receive out of network 
may cost more. Therefore, we decided that the Plan does not have to pay an additional amount for the dental 
services provided from April 23, 2021, to November 5, 2021, by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological examination provided on  
September 24, 2021. 
 
You asked the Plan to pay for the ophthalmological examination. The Plan denied your request. The Plan says 
there are no benefits for routine vision services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that 
the Plan does not have to pay for ophthalmological examination provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided on September 2, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that you were informed that all 
COVID-19 related treatment was fully covered. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 a $10 
copayment for primary care provider services.  
 
You have been asked to pay a $10 copayment for the PCP office visit. Please note that COVID-19 related cost 
share waivers ended on May 31, 2021. The PCP office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a 
primary care physician (PCP) office visit provided on September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits (99215, 99214), 
pelvic ultrasounds (76856), and an ultrasound behind the abdominal cavity (76770) rendered from April 12, 
2021, to September 14, 2021. 
 
You asked the Plan to waive the copayment for specialist office visits, pelvic ultrasounds, and an ultrasound 
behind the abdominal cavity. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says you were charged the correct cost-sharing 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). The Plan contract 
also says that enrollees must pay a $45 copayment for services obtained from a specialist, or under certain 
circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care 
professionals in a specialist's office.  
 
You have been asked to pay $45 for each specialist office visit for nine visits. You have also been asked to pay 
$137.73, which is less than the $155 copayment for a pelvic ultrasound rendered on April 12, 2021, and April 
19, 2021. You have also been asked to pay $105.87, which is less than the $155 copayment for a pelvic 
ultrasound rendered on June 7, 2021, July 19, 2021, and on August 2, 2021. You have also been asked to pay 
$46.70, which is less than the $155 copayment for a pelvic ultrasound rendered on September 14, 2021. You 
have also been asked to pay $108.30, which is less than the $155 copayment for an ultrasound behind the 
abdominal cavity also rendered on September 14, 2021. Specialist office visits fall within the 
physician/practitioner services, including doctors office visits benefit category. Pelvic ultrasounds and 
ultrasounds behind the abdominal cavity fall under 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 specialist office visits 
(99215, 99214), pelvic ultrasounds (76856), and an ultrasound behind the abdominal cavity (76770) rendered 
from April 12, 2021, to September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
without contrast material (70450) provided on October 31, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date. The Plan 
denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, which means that modifiers associated with this pair are allowed. However, an appropriate NCCI modifier was not billed with this PTP 
code edit. This claim was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 of the head or brain without 
contrast material (70450) provided on October 31, 2021.
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 July 26, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you do not want to pay the bill. You say that 
you did not call them directly. You say that you passed out and a Samaritan called an ambulance. You also say 
that the response team brought you back to life and you went home. 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 July 26, 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, no 
transport, (A0998) provided on July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extension of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the extension of SNF services. You say that you require the necessary 
medical treatment that you are receiving in the SNF. The Plan denied your request. The Plan says your request 
does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs 
which would meet the guidelines for continued SNF services. The Plan also says that while you may benefit 
from continuing physical, occupational, and speech therapy, the records do not support the need for daily 
therapy on an inpatient basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the extension of SNF services. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the extension of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extension of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen 3 portable oxygen concentrator. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation as to why the current standard portable equipment 
provided is not meeting medical needs. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the records 
do not include evidence of hypoxemia during activity, or correction with supplemental oxygen using an oxygen 
conserving device. There is no indication that the current portable oxygen system does not meet your 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 the concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Inogen 3 portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on 
September 29, 2021. 
 
You asked the Plan to pay for nursing facility supervision. You say that these services were rendered in good 
faith and were billed appropriately. The Plan denied your request. The Plan says this service has a status 
indicator of B on the CMS Physician Relative Value File, which means this service is always bundled into 
payment for other services and 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. 
 
In this case, CPT 99379 has a status indicator of B  Bundled Code. Payment for covered services are always 
bundled into payment for other services not specified. If Relative Value Units (RVUs) are shown, they are not 
used for Medicare payment. If 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 99379 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules for coverage of nursing facility supervision have not been met. Therefore, we decided that the Plan does not 
have to pay for nursing facility care supervision (99379) provided on September 29, 2021.