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

 
We decided that the Plan does not have to pay for the external ambulatory infusion pump (E0781) provided on 
October 9, 2021. 
 
You asked the Plan to pay for the external ambulatory infusion pump. You say that you would like this claim to 
be reprocessed according to the contracted rate. The Plan denied your request. The Plan says the enrollee 
revoked her hospice coverage on October 04, 2021 and she was not under the care of a hospice provider as of 
the revoke date. The Plan also says that under Medicare guidelines, Original or Traditional Medicare is still 
responsible for payment until the start of the next month after revocation. 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hospice election has been revoked or terminated.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 October 4, 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 external 
ambulatory infusion pump (E0781) provided on October 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
The requested item is statutorily not covered in this case. Based on this information, we decided that Medicare 
rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-
approve a fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on October 
26, 2021. 
 
You asked the Plan to pay for the dental service. You say that the service may have been billed incorrectly. 
You say that your dentist explained to you that what was done was not clinical crown lengthening. You also 
say that your coverage should include all dental procedures up to the benefit amount. The Plan denied your 
request. The Plan says clinical crown lengthening is not listed as a covered service. 
 
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 clinical crown lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
clinical crown lengthening (D4249) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on July 1, 
2021. 
 
You asked the Plan to pay for these services. You say that this claim should be covered by the Plan. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network services provided to the enrollee on 
July 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were forced to go to the ER due 
to faulty lab results and should not be responsible for the copayment. 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 $90 
copayment for each emergency room visit.  
 
The file shows that while you did not request to go to the ER, services were provided. Therefore, you have 
been asked to pay a $90 copayment for the ER visit.  The ER visit falls within the Emergency Care 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 an emergency room (ER) visit provided on November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical conditions are stable with no issues that require a 
physicians evaluation three or more times per week. The enrollee does require physical therapy and 
occupational therapy services, but the provided records do not explain why the intensive inpatient rehabilitation 
therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the enrollee. Based on the medical records provided there is concern that the enrollee will not 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility given her reported very limited tolerance with therapy. Care at the skilled 
nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an esophagogastroduodenoscopy provided 
on October 13, 2021. 
 
You asked the Plan to reduce the copayment for an esophagogastroduodenoscopy. You say that you can only 
be charged a maximum copayment of $110 for a radiological diagnostic service. 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 $260 
copayment for outpatient surgery at an outpatient hospital.  
 
The records show an esophagogastroduodenoscopy is a surgical procedure. You have been asked to pay a $260 
copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 reduce the copayment for an 
esophagogastroduodenoscopy provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), and periodontal scalings and root planings (D4342) of the upper right, upper left, 
lower right, and lower left quadrants provided on November 9, 2021, and November 15, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
scalings and planings. You say that you received treatments and dental procedures that you never asked for. 
You also say that you are disabled, are from Medicare and Medicaid, and you cannot afford or request this 
treatment. The Plan denied your request. The Plan says your benefits for these services have been satisfied and 
the frequency limitations have been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure code every three years and full mouth, or panoramic x-rays are limited to 
one procedure code every five years. The record shows that you received a comprehensive oral evaluation 
(D0150) and panoramic x-rays (D0330) on October 3, 2019 and your comprehensive oral evaluation (D0150) 
and full mouth or panoramic x-rays benefits have been exhausted. The contract also says that scalings and root 
planings are limited to one procedure code every three years, per quadrant. The record shows that you received 
periodontal scalings and root planings (D4341) of the upper right, upper left, lower right, and lower left 
quadrants on November 11, 2019 and your scalings and root planings benefit for each quadrant has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), complete series of intraoral x-rays (D0210), and periodontal scalings and root planings (D4342) of 
the upper right, upper left, lower right, and lower left quadrants provided on November 9, 2021, and November 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 26, 2020, through September 13, 2020, billed with code MLEE1. 
 You asked the Plan to pay for the SNF services as billed. You say that this SNF claim was billed correctly. The 
Plan denied your request. The Plan says there are various issues with the documentation which indicate that the 
billed HIPPS code is not appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that SNF services are paid based on a HIPPS code which 
is calculated, in part, based on the reported active diagnoses for the SNF stay. This information can affect 
several of the case-mix groupings.  
 
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 SNF services as billed. Our reviewer 
says that the documentation does not support the reporting of chronic obstructive pulmonary disease (COPD) 
as an active diagnosis for this SNF stay. Our physician reviewer found the enrollee does have a history of 
COPD; however, she was admitted to this stay due to stroke and end-stage renal disease, and there is no 
evidence of medications or treatment for COPD. As such, COPD does not meet Medicare rules for reporting as 
an active diagnosis. 
 
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 SNF services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 26, 2020, 
through September 13, 2020, billed with code MLEE1.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services (CPT code G0299 
x2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's previously approved visits should have allowed their nurse to review the 
enrollee's medical conditions, medication management, pain management, diet, and household safety with the 
enrollee. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits. 
 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 services. Our physician reviewer 
found the provided 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. The enrollee's urinary infection appears to be resolving with oral antibiotics and no active symptoms. 
No medical notes from the enrollees treating physician are provided documenting an order or need for 
additional skilled nursing services. 
 
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 home health skilled nursing services (CPT code G0299 x2).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy provided on December 10, 2021. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that this was a routine colonoscopy so 
you should not be charged for a diagnostic colonoscopy. The Plan denied your request. The Plan says that the 
copayment amount you are being charged is correct. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. 
Your contract with the Plan says there is no coinsurance, copayment, or deductible for an in-network covered 
colorectal cancer screening exam. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any medical records related to this service. You say that 
this was a screening colonoscopy. Without medical records, we cannot determine whether any services other 
than preventive were performed during this colonoscopy. Therefore, the Plan has not shown that its decision to 
ask you to pay this copayment amount is correct or justified according to Medicare rules and your contract with 
the Plan. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy provided on 
December 10, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response without transport provided on October 
8, 2021. 
 
You asked the Plan to pay for emergency response without transport. You say that you did not know you would 
have to pay for the ambulance even if you did not use the transport.  The Plan denied your request. The Plan 
says that emergency response without transport is not covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on October 8, 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 ambulance response 
without transport provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that it is hard for you to eat. You 
say that you no longer have partials because they broke in half, and you need the partials to eat. The Plan 
denied your request. The Plan says partial dentures are not a covered 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 pre-approve a 
mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 14, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that this service should be covered as you 
have a $1,000 coverage limit that you had not met prior to the date in question. The Plan denied your request. 
The Plan says you previously had periodontal maintenance on July 1, 2021, which is less than 6 months before 
the date in question. Your benefit covers periodontal maintenance once every 6 months. 
 
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. Periodontal cleanings may be 
covered once every 6 months following active periodontal therapy, not to be combined with regular cleanings. Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance is 
requested in a frequency that is not covered under this benefit. Documentation shows you had periodontal 
maintenance less than 6 months before the date in question, and the services were covered by the Plan at that 
time. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on October 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve additional occupational visits. You say that the requested additional OT 
visits are medically necessary. The Plan denied your request. The Plan says the requested additional OT visits 
do not meet criteria. 
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 pre-approve additional occupational visits. 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 you have had prior OT and the documentation does 
not reveal that you require the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional occupational visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve three (3) additional occupational therapy (OT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 11, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of code 93976 provided on October 11, 
2021. 
 
You asked the Plan to pay for the additional unit. The Plan denied your request. The Plan says only one unit of 
this code is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that an additional unit of CPT code 93976 is not supported in the medical record. Specifically, the 
records show that only one duplex scan was provided on the date of service in question. The Plan has already 
processed and paid for one unit of code 93976. The requested additional unit is not supported. Based on this 
information, we decided that Medicare rules for coverage of the additional unit have not been met. Therefore, 
we decided that the Plan does not have to pay for the additional unit of code 93976 provided on October 11, 
2021.