Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve left ventricular assist device (LVAD) driveline supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a history of congestive 
heart failure. The LVAD was implanted on February 25, 2019 as a bridge to a potential heart transplant. Caring 
for the driveline exit site is important to reduce the risk of infection. The documentation supports that driveline 
stabilization supplies are medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve left ventricular assist device (LVAD) driveline supplies.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by a participating 
provider on November 19, 2021. 
 
You asked the Plan to pay for a bone replacement graft. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D7953 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided by a participating provider on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation rendered on October 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 (blood smear interpretation) has a 
PC/TC indicator of 8. The file shows that the code was billed with place of service code 22 for outpatient 
hospital and the services are not payable as billed. Therefore, we decided that the Plan does not have to pay for 
the blood smear interpretation rendered on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve driveline management supplies to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON driveline management supplies. You say that the supplies are 
medically necessary and supported by the documentation provided. You say that the hospital doesn't provide 
these supplies. The Plan denied your request. The Plan says the requested supplies are not unusual and can be 
obtained from network companies. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the driveline management supplies at issue in this appeal. We found no exception 
that would require the Plan to pre-approve driveline management supplies from an OON provider. Therefore, 
we decided that the Plan does not have to pre-approve driveline management supplies to be provided by an out-
of-network (OON) provider.
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 November 12, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your wife called an ambulance. You say that 
the paramedics advised they would take you to the hospital, but you may have to sit there all day since the 
emergency room was so busy. You say that you decided not to go to the emergency room. You also say that 
this should be covered. 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 November 12, 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 November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 15, 2021, to 
September 21, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
 You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not 
supported as the principal diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. The Plan argues that DRG 193 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the principal diagnosis of sepsis, unspecified organism (A41.9) is not supported in the 
record. Our physician reviewer found that the documentation indicates that the enrollee was admitted with a 
diagnosis of pneumonia. There was no clinical or laboratory evidence of sepsis. The review has determined that 
the medical records did not support the billing of sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from September 15, 2021, to September 
21, 2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 12, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not 
enrolled in hospice on the date of services in this case. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 7, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care 
(99223) provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that the enrollee has not been seen by the specialty 
before May 21, 2021. The Plan denied your request. The Plan says the Medicare definition of a new patient has 
not been met. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99203 is not supported. Previous evaluation and 
management services were billed from the same physician group practice within the last 3 years. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits (99213) provided from 
December 18, 2021, through December 20, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $40 
copayment for each specialist visit.  
 
You have been asked to pay $120 ($40 copayment x 3) for the specialist visits provided on December 18, 2021, 
December 19, 2021, and December 20, 2021.  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 copayments for the office visits (99213) provided from 
December 18, 2021, through December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services (99100) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the special anesthesia services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status 
indicator of B. 
 
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 99100 is not supported in the record. Specifically, CPT code 99100 has a status 
indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for 
another service. Based on this information, we decided that Medicare rules for coverage of the special 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special 
anesthesia services (99100) provided on November 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast tomosynthesis (77063) and screening 
mammography (77067) provided on July 21, 2021. 
 
You asked the Plan to pay for the imaging services. You say that the enrollee received multiple exams on the 
date in question The Plan denied your request. The Plan says National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edits exist between codes 77065 and 77063 and code 77067. These PTP edits 
both have a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with these PTP code edits. These services were 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 codes 
77063 and 77067 are both column II codes to column I code 77065. 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 breast tomosynthesis (77063) and 
screening mammography (77067) provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc (J7324). The Plan denied your request. The Plan says per the 
clinical notes submitted, the medication, Orthovisc will be supplied by a pharmacy. The Plan also says that the 
Medicare rules say in order for the request to be eligible for coverage under the member's medical benefit, the 
medication must be supplied by the member's ordering medical provider or medical facility. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300). 
 
You asked the Plan to pre-approve the direct skilled nursing services of a RN and LPN. The Plan denied your 
request. The Plan says the submitted documentation shows these services are custodial in nature. 
 
  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. 
 
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 direct skilled nursing services of a 
RN and LPN. Our reviewer says that the direct skilled nursing services of a RN and LPN are not medically 
reasonable and necessary. Our physician reviewer found there is no documentation that skilled nursing services 
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, 
or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
Our reviewer found that the records do not document any acute or unstable medical conditions or changes in 
medication or treatment which would necessitate any further skilled nursing visits beyond what have already 
been approved. No medical notes from the enrollees treating physician are provided documenting a need for 
additional skilled services. Our physician reviewer also found that the records do not document the need for 
intravenous medications, new tube feeding or ostomy care, or daily complex wound 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 the direct skilled nursing services of a RN and LPN have not been met. 
Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered 
nurse (RN) (G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from July 15, 2021, 
to July 29, 2021. 
 
You asked the Plan to pay for the home health care services. You say that the RAP was received, it was just 
beyond the 5 days. You also say that you would like the final claim to be reconsidered for payment. The Plan 
denied your request. The Plan says the RAP claim for the services provided from July 15, 2021, to July 29, 
2021 was not submitted until August 23, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, July 15, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided from July 15, 2021, to July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided by an out-of-network 
provider on August 9, 2021. 
 
You asked the Plan to pay for a core build-up. You say that you feel like the Plan should reimburse you. The 
Plan denied your request. The Plan says D2950 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided by an out-of-network provider on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), maxillary partial denture 
(D5213), and mandibular partial denture (D5214) provided on November 8, 2021. 
 
You asked the Plan to pay for the preventive procedure and partial dentures. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says that neither you, 
nor your provider, contacted the Plan prior to the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999), maxillary partial denture (D5213), and mandibular partial denture (D5214) 
provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain fused to metal crown (D6059) provided on January 3, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal 
crown. You say that your contract says that the Plan would pay 50% for the crown and you have a $3,000 
allowance. You also say that you would like the Plan to pay for half of the crown. The Plan denied your 
request. The Plan says these services are not covered. The Plan also says that you signed a consent for 
treatment that says you agreed to be responsible for all services rendered on your behalf. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided 
on January 3, 2022.