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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on February 18, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transport and ground mileage. You say that you 
believe it was medically necessary to be transported to the other facility because you could not walk or drive. 
The Plan denied your request. The Plan says you did not meet the criteria for coverage. 
 
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-emergency ambulance transport and 
ground mileage. Our reviewer says that the documentation does not support that the ambulance transport on 
February 18, 2022 was medically reasonable and necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for you. Our reviewer also found that the documentation does not support 
that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance could provide for safe transport on February 18, 2022. 
 
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-emergency ambulance transport and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) 
and ground mileage (A0425) provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00811) provided to the 
enrollee on February 22, 2022. 
 
You asked the Plan to pay for the services. You say that this was billed with the appropriate modifiers. The 
Plan denied your request. The Plan says the procedure code is inconsistent with the modifier used. 
 
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 00811 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record includes an 
anesthesia report documenting procedure "Colon".  The documentation does not confirm what procedure or 
what the anesthesia services were provided for. In this  case modifier 33 cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 00811) provided to the enrollee on February 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office or other outpatient visit (99214) billed for date of service 
October 21, 2021. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
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, the Plan has denied citing a rule that applies to institutional rather 
than professional claims. It is the Plan's responsibility to substantiate its denial. In this case, the denial has not 
been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for an office 
or other outpatient visit (99214) billed for date of service October 21, 2021. 
 
Please note that, if the Plan has previously paid for procedure code 99213, our decision would only require the 
Plan to pay the difference in the fee-schedule amount between codes 99213 and 99214. 
 
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 services (86077) provided on December 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 the services (86077) 
provided on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 
August 30, 2021 billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, custom fabricated abutments, and surgical 
implant placements. 
 
You asked the Plan to pre-approve extractions, custom fabricated abutments, and surgical implant placements. 
You say that the enrollee needs this treatment due to a car accident in 2007. The Plan denied your request. The 
Plan says only 2 extractions are covered per year. The Plan also says that custom fabricated abutments and 
surgical implant placements 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, only 2 extractions are covered per 
calendar year. The Plan previously approved 2 extractions, which exhausted your benefit. In addition, custom 
fabricated abutments and surgical implant placements are not covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve extractions, custom fabricated abutments, and surgical implant 
placements.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alarm or alert device. 
 
You asked the Plan to pre-approve the alarm or alert device. You say that this is necessary for your condition. 
The Plan denied your request. The Plan says this device is not covered by Medicare or the Plan. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve the alarm or alert device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been bed bound since October and need 
physical therapy to be able to walk. You say that your health is deteriorating due to not being able to walk and 
going to therapy is urgent. The Plan denied your request. The Plan says care can be received in another setting. 
 
  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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve block procedure (64624) provided March 23, 2022. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim did not include a valid diagnosis code. 
 
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 64624 is not supported in the medical record. Specifically, per Local Coverage Article 
Billing and Coding: Peripheral Nerve Blocks (A57452), the claim was not billed with a covered diagnosis 
code. Based on this information, we decided that Medicare rules for coverage of the procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for a nerve block procedure (64624) provided 
March 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case.  Our physician reviewer found it was not expected that this enrollee would require hospital services that would 
likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program provided on 
October 25, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request. 
The Plan says the claim processed with the correct copayment. 
 
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 $35 
copayment for Vision Care-Medicare-covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $35 copayment for the ophthalmological services. The ophthalmological services falls within the Vision Care-Medicare-covered exams to diagnose and treat diseases of the eye 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 ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services that were requested on June 20, 2022, and 
denied on July 5, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you have a gum infection, and this is 
causing pain. As such, this must be approved. The Plan denied your request. The Plan says that services were 
received in February 2019, and this exhausted the benefit for the services requested at this time. 
 
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. Based on the information provided by the Plan, we cannot confirm that the 
denial for the unspecified services was correct. The file references several different services, and despite 
requests to the Plan, we are unable to determine what services are at issue. The appeal request clearly indicates 
that the services were originally requested on June 20, 2022, and were denied on July 5, 2022. The denial 
notice for that date was not submitted when requested. Since we were not provided with evidence of the 
services at issue, we cannot determine that the Plan correctly denied them. As such, the denial of the dental 
services that were requested on the date referenced is not substantiated. Therefore, we decided that the Plan has 
to pre-approve the dental services that were requested on June 20, 2022, and denied on July 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) supplies 
provided on March 14, 2021. 
 
You asked the Plan to pay for the CPAP supplies. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the items billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a recent valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Review of the file shows that the while there is a physician 
order in the case file, it is from 2019. In addition, the latest medical records provided were also from 2019. This 
means that that this claim is not payable as billed. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous positive airway pressure (CPAP) supplies provided on March 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for PET imaging have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare continues to nationally non-cover initial 
anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. Based on 
this information, we decided that Medicare rules for coverage of a PET-CT scan have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a PET-CT scan (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sunglasses frames and progressive polaroid lens provided on 
February 1, 2022. 
 
You asked the Plan to pay for sunglasses frames and progressive polaroid lens. The Plan denied your request. 
The Plan says that the Plan does not cover lens upgrades, including but not limited to deluxe frames, transition, 
progressive, scratch resistant, polish or tinted lenses, or insurance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan does not cover lens upgrades. Therefore, 
we decided that the Plan does not have to pay for sunglasses frames and progressive polaroid lens provided on 
February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on December 16, 2021. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids 
rendered were not part of the approved list of hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not part of the approved list 
of hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intubation and critical care services provided to the enrollee 
on November 18, 2021. 
 
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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 31500: 
 
Intubation, endotracheal, emergency procedure 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 31500, the 
records do not include documentation of an intubation procedure, and therefore cannot be verified as 
performed. The procedure report documents "INTUBATED UNRESPONSIVE." The medical record does not 
confirm this procedure was performed during evaluation and management service. In terms of CPT 99291, the 
medical records do not include a critical care report to confirm that critical care services provided, and the time 
that the services were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intubation and critical care services provided to the enrollee on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Straight Tip Urine Catheter. 
 
You asked the Plan to pre-approve the item. You say that problems have been ongoing for six months. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a Straight Tip Urine Catheter.