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

 
We decided that the Plan does not have to pre-approve the vacuum assisted suspension system (VASS) for a 
prosthetic leg. 
 
You asked the Plan to pre-approve the VASS for a prosthetic leg. You say that you would like reconsideration 
because the requested prosthetic is medically necessary. The Plan denied your request. The Plan says the VASS 
exceeds your medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VASS for a prosthetic leg. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the VASS exceeds your medical needs and is not proven superior to a 
standard socket. 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 VASS for a prosthetic leg have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the vacuum assisted suspension system (VASS) for a prosthetic leg.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 22, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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 code 76380 is computed tomography, limited or localized 
follow-up study. We find that CPT code 76380 may be eligible for payment when billed with code 37243. The 
claim information does not show that the code at issue was billed with a modifier suitable for payment. 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 computed tomography (CT) scan provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), bitewings - four 
radiographic images (D0274), and periodic oral evaluation - established patient (D0120) provided September 
17, 2021. 
 
You asked the Plan to pay for the dental cleaning, bitewing x-rays and periodic oral exam. You say that you are 
not asking for the provider to be paid, you are asking for reimbursement for the money you paid. The Plan 
denied your request. The Plan says these services are not covered because the provider has opted out of 
Medicare. 
 
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 dental cleaning, bitewing x-rays and periodic oral exam when you see any licensed dental 
provider who accepts Medicare patients in the United States and has not opted out of Medicare.  
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the dental cleaning, bitewing x-rays and periodic oral exam 
have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult 
(D1110), bitewings - four radiographic images (D0274), and periodic oral evaluation - established patient 
(D0120) provided September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires (A4557) provided on September 22, 2021. 
 
You asked the Plan to pay for the lead wires. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says no separate payment is available for this item per 
Medicare rules. 
 
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 A4557 is lead wires, pair. 
We looked at the file and Medicare rules. In this case, the requested Status Code under the Physician Fee 
Schedule is "P" indicating Bundled/Excluded Codes. This means that there are no Relative Value Units and no 
payment amounts for these services. No separate payment should be made for them under the fee schedule. 
Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. 
Therefore, we decided that the Plan does not have to pay for the lead wires (A4557) provided on September 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam (D2140) provided on November 16, 2021. 
 
You asked the Plan to pay for the amalgam. You say that this amalgam filling was provided due to recurrent 
decay. You also say that you would like this claim to be reconsidered for coverage. The Plan denied your 
request. The Plan says fillings are not a covered benefit under the enrollee's medical plan, and the enrollee does 
not have a dental plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the amalgam 
(D2140) provided on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2020. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service 
November 9, 2021. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 76705 is bundled into payment for 93976.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 procedure code 76705-26 billed for date of service November 9, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, with no transport 
(A0998) provided on October 17, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 17, 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, with no 
transport (A0998) provided on October 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
10, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 10, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 21, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 21, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation services 
provided from June 22, 2021, to July 30, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the ambulance was 
the only method of transportation that would work. You say that the enrollee was supposed to have non-
emergency transportation. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each one-way ambulance trip. This applies to both emergency and non-
emergency transportation.  The enrollee has been asked to pay a $250 copayment for each of the ambulance transportation services, for a 
total of $500. The ambulance transportation falls within the Ambulance Services benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayments for ambulance transportation services provided from June 22, 
2021, to July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical switch (E2311) and a positioning wedge 
(K0108). 
 
You asked the Plan to pre-approve the electrical switch and positioning wedge.. You say that these items are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power tilt seating system (E1002) includes a 
motor and related electronics with or without variable speed programmability and a switch control which is 
independent of the power wheelchair drive control interface. The rules also state that K0108 cannot be used for 
any cushion component as these codes are all-inclusive. 
 
We looked at the file and Medicare rules. The power features already approved include their own switches. 
Code K0108 cannot be used for cushion components. Based on this information, we decided that Medicare 
rules for coverage of the electrical switch and positioning wedge. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical switch (E2311) and a positioning wedge (K0108).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance 
service (A0428) provided on October 8, 2021. 
 
You asked the Plan to pay for the ground mileage and non-emergency ambulance service. You say that you 
would like this denial to be overturned based on the medically necessary services that were rendered. The Plan 
denied your request. The Plan says the criteria for coverage has not been met. 
 
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 ground mileage and non-emergency 
ambulance service. Our reviewer says that the documentation does not support that the ambulance transport on 
October 8, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van or wheelchair van) were 
contraindicated for this patient. Our reviewer also found that the documentation does not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance can provide for safe transport on October 8, 2021. 
 
 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 ground mileage and non-emergency ambulance service have not been met. 
Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency 
ambulance service (A0428) provided on October 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0422) provided to the enrollee on 
August 13, 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 this service is not allowed as a separate charge. 
 
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 A0422 is "Ambulance (als or bls) oxygen and oxygen 
supplies, life sustaining situation." 
 
We find that CPT code A0422 is not supported in the medical record. Specifically, it is not appropriate to 
report this code separately. 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 ambulance services 
(A0422) provided to the enrollee on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is not safe to leave the hospital at this time, because the respiratory status 
is not yet stable, and may be worsening. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be somewhat unstable still and should only require short-term 
additional acute care services that can be safely administered at the current facility until more stable. The 
enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered 
when treatment has completed and the patient is more stable. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services received on October 6, 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 provider is not eligible. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. The services must be performed by a qualified physician. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were provided by a licensed 
acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for acupuncture 
services received on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on August 17, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you really need these stockings to 
alleviate swelling in your legs. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480-26 billed for date of service 
November 16, 2021. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70480 is bundled into payment for 70450.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
70480-26 is a column II code to column I code 70450. 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 procedure code 70480-26 billed for date of service 
November 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a front wheeled walker with supervision, cueing or steadying assistance and is 
supervision, cueing or steadying assist for transfers. Provided records do not document a significant decline in 
the enrollees functional status compared to his recent baseline to necessitate daily inpatient skilled therapy 
services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 17, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 17, 
2021.