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

 
We decided that the Plan does not have to pay for the conductive garment for transcutaneous electrical nerve 
stimulation (tens) coded E0731 provided on December 16, 2021. 
 
You asked the Plan to pay for the conductive garment. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says required documentation is missing to support this service. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation does not include medical records that support the necessity of the item 
rendered. 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 conductive garment for 
transcutaneous electrical nerve stimulation (tens) coded E0731 provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27762-54-RT billed for date of service 
August 21, 2021. 
 
You asked the Plan to pay for procedure code 27762-54-RT. You say that these services were billed correctly. 
The Plan denied your request. The Plan says procedure code 27762-54-RT is not supported in the medical 
record. The submitted medical records indicate that closed treatment of medial malleolus fraction was 
performed but it does not indicate that manipulation was performed. 
 
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 27762 is closed treatment of medial malleolus fracture; 
with manipulation. 
 
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 procedure code 27762-54-RT. Our reviewer says that 
procedure code 27762-54-RT is not supported in the medical record. Our reviewer found the CPT code 
description includes the words "with manipulation". In this case, the procedure report does not include documentation manipulation was performed, and therefore this procedure cannot be verified. The procedure 
report documents "Manipulation performed: no".  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27762-54-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 27762-54-RT billed for date of service August 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
December 6, 2021, to December 8, 2021, and from December 28, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the SNF services. You say that these services were medically necessary The Plan 
denied your request. The Plan says for dates of service December 6, 2021, to December 8, 2021, and December 
28, 2021, to December 31, 2021, the patient's care was custodial and the SNF services were not medically 
necessary. The Plan has paid for SNF services prior to December 6, 2021, and from December 9, 2021, to 
December 27, 2021. 
 
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 pay for the SNF services. Our reviewer says that 
these SNF services were not medically necessary. Our physician reviewer found on the dates of service in 
question, the patient had no identifiable skilled nursing needs or skilled therapy needs. The patient did not 
require skilled nursing or skilled therapy on a daily basis in an inpatient SNF setting. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from December 6, 2021, to December 8, 
2021, and from December 28, 2021, to December 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echo guidance for biopsy rendered on January 20, 2022. 
 
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 separately payable. 
 
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 76942 is a column II code to column I code 74174. 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 echo guidance for 
biopsy rendered on January 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from April 
22, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee's status will decline without 
intensive therapy provided in an SNF. The Plan denied your request. The Plan says continued skilled nursing 
facility services are not necessary after April 21, 2022, and the enrollee could be treated in an alternate setting 
after this date. 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 continued SNF care. Our reviewer says 
that continued SNF care is not medically necessary after April 21, 2022. Our physician reviewer found that the 
enrollee does not have any identifiable skilled nursing service needs which require the specialized skill, 
knowledge and judgement of a skilled professional nurse to safely and effectively provided medically 
necessary and reasonable treatment. From a nursing perspective, the enrollee received oral medications and had 
stable vital signs. There are no identifiable skilled therapy service needs which require the specialized skill, 
knowledge and judgement of a qualified therapist. The enrollee is at a supervision/stand by assist level of 
functional mobility including gait to 150 feet with a rolling walker. This beneficiary does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from April 22, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Endoscopy Procedures provided on October 26, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Endoscopy Procedures. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Endoscopy Procedures provided on October 26, 
2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan of arm joint without contrast (73221). 
 
You asked the Plan to pre-approve an MRI scan of arm joint. You say that you are in severe pain and cannot do 
any type of physical therapy. The Plan denied your request. The Plan says this test is not medically necessary at 
this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan of arm joint. Our reviewer 
says that an MRI is not medically necessary. Our physician reviewer found that the physical exam from April 
4, 2022, regarding the right shoulder is limited to a comment "decreased range of motion". No detailed physical 
exam with respect to possible rotator cuff tear, impingement etc., plain film report, or notes from physical 
therapy describing an inability to pursue such therapy has been provided. Without any of the above data points 
the medical necessity of the requested MRI of the right shoulder has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of arm joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI scan of arm joint without contrast (73221).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan has to pre-approve left eye keratoplasty/partial corneal transplant for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that medical need has not been met because a keratoplasty/partial 
corneal transplant is not approved by Medicare and/or the FDA when done to only to improve your vision. 
 
The Plan must follow Medicare rules. Medicare rules say that keratoplasty that treats specific lesions of the 
cornea, such as phototherapeutic keratectomy that removes scar tissue from the visual field, deals with an 
abnormality of the eye and is not cosmetic surgery and may be 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The requested 
keratoplasty is requested to treat a specific lesion of the cornea, and is not to treat a refractive defect, and is not 
considered cosmetic. Endothelial keratoplasty is considered a standard of care in the treatment of early to 
moderate Fuchs' endothelial dystrophy. Our physician reviewer found that the enrollee's condition meets 
criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve left eye keratoplasty/partial corneal transplant for the enrollee.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 19, 2020. 
 
You asked the Plan to pay for ambulance services. You say that you would like the claim processed and paid. 
The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on November 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 12 units of ambulance mileage (A0425) provided on August 
2, 2021. 
 
You asked the Plan to pay for ambulance mileage. You say that these services were necessary and are 
supported in the record. The Plan denied your request. The Plan says ambulance mileage has an MAI of 1 with 
an MUE of 250. This means that only 250 units of ambulance mileage may be billed on a single line, and 
additional units must be reported on a separate line. The submitted claim reports 262 units on one line; 
therefore, the Plan has approved 250, and the additional 12 which exceed the MUE for this service units are 
denied. The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim. Each line of the claim with that 
HCPCS/CPT code will be separately adjudicated against the MUE value for that HCPCS/CPT code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 262 units of 
this code on a single claim line, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of 12 units of ambulance mileage have not been met. Therefore, we decided that the Plan does not 
have to pay for 12 units of ambulance mileage (A0425) provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomic (PGx) testing provided 
on October 8, 2021. 
 
You asked the Plan to pay for the PGx testing. You say that this testing was ordered by the treating physician 
due to medical necessity. The Plan denied your request. The Plan says this testing is not billed correctly as it 
should be reported with a single code. 
 
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 documentation does not support that this testing was ordered by 
a provider who is treating the enrollee for a specific medical problem. The progress note submitted does not 
support that the provider had a visit with the enrollee, nor why the testing was ordered or how it would be used 
for treatment management. Based on this information, we decided that Medicare rules for coverage of the PGx 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive 
pharmacogenomic (PGx) testing provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a hearing aid warranty provided on  
January 18, 2021. 
 
You asked the Plan to reimburse you for a hearing aid warranty. The Plan denied your request. The Plan says a 
hearing aid warranty is not a covered benefit by the Plan. 
 
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 the Plan does not provide coverage for a hearing aid 
warranty. Therefore, we decided that the Plan does not have to reimburse you for a hearing aid warranty 
provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) provided May 12, 2021. 
 
You asked the Plan to pay for the cone beam CT scan. You say that you did not want any services not covered 
by your plan. The Plan denied your request. The Plan says this service is not covered under your 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, 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 cone 
beam computed tomography (CT) capture and interpretation with limited field of view  less than one whole 
jaw (D0364) provided May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns - porcelain fused to high noble metal (D2750) for teeth 6, 
7, 10, and 11. 
 
You asked the Plan to pre-approve crowns. You say that you would like the crowns to be covered. The Plan 
denied your request. The Plan says that you do not meet criteria for the crowns. 
 
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. In this case we sent a request to the Plan for diagnostic quality x-rays. We did 
not receive a response to our request. The photocopies provided in the original appeal are not sufficient to 
verify the Plans denial based on medical necessity. Therefore, we decided that the Plan has to pre-approve 
crowns - porcelain fused to high noble metal (D2750) for teeth 6, 7, 10, and 11.  
 
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 an immediate denture (D5140), and an extraction (D7140), 
provided by a participating provider on December 30, 2021. 
 
You asked the Plan to pay for an immediate denture and an extraction. You say that you believe the Plan 
should be paying for this. The Plan denied your request. The Plan says the member's annual dental maximum 
allowance amount of $1,000 has already been met and exhausted. 
 
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.  
 
We looked at the file and Medicare rules. The Plan paid the remaining $843 towards the annual maximum 
dental amount of $1,000. The enrollee is responsible for any amount over the $1,000 dental annual maximum 
amount. Based on this information, we decided that the Plan's rules for coverage of an immediate denture and 
an extraction have not been met. Therefore, we decided that the Plan does not have to pay for an immediate 
denture (D5140), and an extraction (D7140), provided by a participating provider on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) and bone graft at time of 
implant placement (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you found out implants would not be 
covered. You say that you canceled your policy immediately by phone. You also say that you are not getting a 
bill for nothing done or paid for. The Plan denied your request. The Plan says the requested implant placement 
and bone graft are not listed as covered services. 
 
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 implant placement and 
bone graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve implant placement (D6010) and bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve the drugs or medicaments. You say that you do not want dentures, or your 
front teeth removed. You also say that you want a bridge. The Plan denied your request. The Plan says this 
service is not covered under your benefit package. 
 
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 
drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970, 
and 84100) provided on December 9, 2021. 
 
You asked the Plan to pay for codes 82310, 82728, 83540, 83550, 83970, and 84100. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 
not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82728, 83540, 83550, 83970, and 84100) provided on December 9, 2021.