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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs may be met at a lower level of care. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of 
care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. It is not clear 
what her previous functional status was but at this time her profound weakness and cognitive impairment 
appear to be preventing her from participating in therapy in a meaningful way. Admission to a SNF for 
inpatient skilled rehab services is not 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an ImpediMed L-Dex Bioimpedance Device 
(93702) x 8 (bioimpedance spectroscopy). 
 
You asked the Plan to provide coverage for this service. You say that this claim should be paid. The Plan 
denied your request. The Plan says medical necessity has not been established.  
 
The Plan must follow Medicare rules. Medicare pays for services determined to be medically necessary.  
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 this service. Our reviewer says that medical necessity has not 
been established. Our reviewer found the requested bioimpedance spectroscopy is not medically necessary per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) as Medicare does not pay for any items 
or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The literature is insufficient to determine the overall health 
outcomes on bioimpedance spectroscopy for use in the diagnosis of management of patients with lymphedema. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to provide coverage for an ImpediMed L-Dex Bioimpedance Device (93702) x 8 (bioimpedance 
spectroscopy).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (G0463, 93978, 96127) provided on May 
19, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-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 service 
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 surgical services (G0463, 93978, 96127) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 17, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says these services are not authorized because screening testing is not a Medicare benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is not a medical necessity given the enrollee's diagnosis of discolored thick toenails. The review has 
determined that the services at issue in this case were not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
December 31, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says screening panels/testing with no relation to a medical diagnosis of disease 
are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation indicates that there was no specific clinical rationale to the obtained tests. This testing 
would not be covered benefit for a diagnosis of cough.  The review has determined that the services at issue in this case are not medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for plaque removal by a specialist physician 
(code 37229), a computed tomography (CT) scan (code 74176), Part B medications (code J3010, J0690, J2405, 
J2250, J7040, and J7042), and an angiogram (code 75710) provided on April 15, 2021. 
 You asked the Plan to waive the cost sharing for plaque removal, the CT scan, Part B medications, and 
angiogram. You say that the provider made a mistake when they were performing the procedure. You say you 
should not be held responsible for the charges. 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 $20 
copayment for surgical services provided by a specialist. Your contract with the Plan clearly says that you must 
pay a $50 copayment for a CT scan. Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B medications. Your contract with the Plan clearly says that you must pay a $75 
copayment for an angiogram. 
 
You have been asked to pay a $20 copayment for plaque removal provided by a specialist. Specialist physician 
services fall within the Physician/Practitioner Services, including Doctor?s Office Visits benefit category.  
 
You have also been asked to pay a $50 copayment for a CT scan. CT scans fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
 
You have also been asked to pay 20% coinsurance of the allowed amount for Part B medications. The total 
allowed amount for the medications is $8.24, and 20% of that is $1.65. Part B medications fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
 
You have also been asked to pay a $75 copayment for an angiogram. Angiograms fall 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 cost sharing for plaque removal by a specialist physician (code 37229), a 
computed tomography (CT) scan (code 74176), Part B medications (code J3010, J0690, J2405, J2250, J7040, 
and J7042), and an angiogram (code 75710) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sinus augmentation (D7952), surgical placement of an 
implant body (D6010 x 2), and limited oral evaluation (D0140) provided from April 7, 2021, to May 3, 2021. 
 
You asked the Plan to pay for the sinus augmentation, implants, and oral exam. You say that you called the 
Plan in March 2021 to change your plan. You say that you told them you would need implants. You say that 
you were never advised that implants would not be covered. You also say that you feel that up to your 
maximum coverage of $2,000 should be available to pay for the implants. The Plan denied your request. The 
Plan says the sinus augmentation is not listed as a covered service. The Plan says that the implants are not listed 
as covered services. The Plan says that the limited oral evaluation is not listed as a covered service either. 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 sinus augmentation, implants, and 
oral exam are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the sinus augmentation (D7952), surgical placement of an implant body (D6010 x 2), and limited oral 
evaluation (D0140) provided from April 7, 2021, to May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87798, 88305, 88312, 88313) provided 
on April 4, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 service 
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 lab services (87481, 87798, 88305, 88312, 88313) provided on April 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on May 19, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
 
 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 the office visit and related services provided on 
May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided May 26, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services including mileage. You say that the 
ambulance transport was not necessary. The Plan denied your request. The Plan says the copayment was 
applied 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 $200 
copayment per one way trip by ambulance.  
 
You have been asked to pay a $200 copayment for the ambulance services and mileage. The ambulance 
services including mileage fall within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) 
and ground mileage (A0425) provided May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial lower denture (D5214). 
 
You asked the Plan to pre-approve the partial lower denture. You say that you would like reconsideration 
because the partial denture is medically necessary to prevent the tooth from shifting. The Plan denied your 
request. The Plan says the member is not missing enough teeth to affect chewing function. 
 
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 covers the partial 
lower denture when the services are medically necessary and reasonable.  
 
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 partial lower denture. Our reviewer 
says that Partial dentures are not a covered benefit when 8 or more (natural or prosthetic) posterior teeth are in 
occlusion. In this instance there are more than eight posterior teeth in occlusion even if the retained primary 
molars are removed. 
 Our physician reviewer found other methods of retention may be appropriate to prevent tooth drift, however 
under the Plan there are sufficient remaining contacts and therefore no medical necessity for the requested 
partial denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the partial lower denture have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0202U) provided November 17, 2020. 
 You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service was for screening purposes and is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
services (0202U) provided November 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services provided on  
May 21, 2021. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like 
reconsideration because this transport was medically necessary. The Plan denied your request. The Plan says 
the member could have been safely transported by another vehicle. 
 
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 the non-emergent ambulance services. Our 
reviewer says that the documentation does not support that other means of transport (such as stretcher van) 
were contraindicated. The documentation does not support that the member needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.  
 Our physician reviewer found the documentation does not support that the ambulance transport was medically 
reasonable and necessary for the member. 
 
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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent ambulance services provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuropathy treatment services provided on May 27, 2021, 
through June 17, 2021. 
 
You asked the Plan to pay for the neuropathy treatment services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the neuropathy treatment services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient objective evidence of before and after findings from 
previous treatments or description of the treatment to help justify this request. 
 
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 neuropathy treatment services have not been met. Therefore, we decided that the Plan does not have to pay for the neuropathy treatment services provided on May 27, 2021, through 
June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report 
provided on April 2, 2021 billed with code 93010 
 
You asked the Plan to pay for the billed code 93010. You say that this was a contemporaneous report and not 
simply a review of the radiologist's findings. The Plan denied your request. The Plan says this was not billed 
with a required modifier. 
 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 the billed 
code 93010 is a column II code to column I code 31500. 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 electrocardiogram (ECG) interpretation and 
report provided on April 2, 2021 billed with code 93010
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for continued physical therapy. 
 
You asked the Plan to provide coverage for continued physical therapy. You say that this treatment is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 provide coverage for continued physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found he additional requested therapy is not 
generally accepted as specific and effective therapy for your condition beyond what was approved by the health 
plan. You had prior therapy of approved of 20 outpatient visits and the records do not demonstrate that the 
ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. You have been instructed in a home exercise program. The requested services are not part of a 
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. Medicare coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued physical therapy have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for continued physical therapy.