Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 2, 2021. 
 
You asked the Plan to pay for the dental service. You say that the services you received were performed on an 
emergency basis. You say that you were experiencing significant tooth pain. You say that you were not 
confident your previous provider could perform the necessary services in office. You also say that you feel 
these services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation 
is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on May 3, 2021. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) provided on December 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, 
A0425) provided on October 10, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that these services were medically necessary, 
and the enrollee was non-ambulatory and a fall risk on the date in question. The Plan denied your request. The 
Plan says the documentation does not support that the enrollee could not have been transported by other means 
on the date in question. 
 
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 ambulance transport. Our reviewer says 
that the ambulance transportation was not medically necessary in this case. Our physician reviewer found that 
the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this enrollee on October 10, 2021. The 
documentation does not support that the enrollee required the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport on October 10, 2021. 
The documentation does not support that these services were medically reasonable and necessary on the date in 
question. 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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on 
October 10, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on October 15, 2020, through 
November 5, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on October 15, 2020, through November 5, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, 83550) provided on 
October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider reported routine lab services 
related to the treatment of end stage renal disease (ESRD), which does not follow industry standard coding 
rules. 
 
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 (82728, 83540, 83550) provided on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 1, 2021, 
to February 3, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the billing information for these services is 
incomplete; specifically, a diagnosis is missing the Present on Arrival (POA) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the claim shows that diagnosis R19.7 (diarrhea, unspecified) was billed with these services, but no POA 
indicator is provided for this diagnosis.  This diagnosis is not among those on the Centers for Medicare and Medicaid Services exception list, which 
means that a POA indicator is required. A corrected claim may be submitted to the Plan directly. Based on this 
information, we decided that Medicare rules for coverage of the inpatient care have not been met. Therefore, 
we decided that the Plan does not have to pay for the inpatient hospital care provided from February 1, 2021, to 
February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wigs (A9282) provided on December 1, 2021. 
 
You asked the Plan to pay for the wigs. You say that you would like the wigs to be covered as a medical 
expense because it helps you live a more normal life and maintain a positive attitude for healing. The Plan 
denied your request. The Plan says these services are not covered by Medicare. The Plan also says that the wigs 
were rendered by a provider who is not under contract with the Plan and is not certified for Medicare. 
 Medicare may pay for items which either meet the definition of durable medical equipment (DME) or a 
prosthesis when these items are ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wigs (A9282) 
provided on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 4, 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 there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 77065 is "Diagnostic mammography, including 
computer-aided detection (CAD) when performed; unilateral." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the record indicates that the enrollee 
underwent a procedure. The records provided are insufficient to demonstrate the performance of more than one 
unit of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on October 4, 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 November 18, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the front 
desk at the hotel you were staying at called the ambulance because you started bleeding from an outpatient 
surgery and could not drive. You also say that you drove yourself to the emergency room because there was no 
nighttime cab service, you wanted to get back to the hotel, and also wanted to save ambulance costs. The Plan 
denied your request. The Plan says there was no transport and according to your plan there is no benefit, so you 
are responsible for the billed charges. 
 
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 18, 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 November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on June 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the code was 
performed separately. The Plan denied your request. The Plan says the code is not supported in the 
documentation. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. We find that CPT code 75710 was provided during a vascular procedure. The 
rules ay that open and percutaneous interventional vascular procedures include operative angiograms which 
shall not be separately reported as diagnostic. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the angiography services provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 9, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support additional services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that 1 unit of codes 85610, P9604, G0471, and 80048 were billed and paid for by the plan. 
Another claim was billed for the same units of service on the date at issue. The records provided do not show 
that more than 1 unit of service was provided for each of the codes billed. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0673). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0673).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
12, 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 billed for date of service November 12, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the documentation fails to indicate that the requested chest CT scan has met the 
Medicare medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the record indicates that 
the enrollee has had shortness of breath and has a 2.8 cm by 1.8 cm lesion in the right upper lobe on plain chest 
x-ray in the setting of being a previous smoker and having asbestos exposure. The provided records establish 
the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are satisfied.  
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the chest 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient mental health admission. 
 
You asked the Plan to pre-approve the acute inpatient mental health admission. You say that you would like the 
Plan's decision to be reversed and the continued stay to be authorized for the enrollee until they are stabilized. 
The Plan denied your request. The Plan says an acute inpatient mental health admission is not medically 
necessary as the submitted clinical information does not indicate a medical need for this admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 acute inpatient mental health 
admission. Our reviewer says that the enrollee does not meet the Medicare criteria for a continued acute 
inpatient mental health admission. Our physician reviewer found that it is not expected that the enrollee will 
improve in a reasonable period of time beyond the date in question as the enrollee was not showing any 
dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors. The enrollee is noted 
to be cooperative and compliant with treatment while not showing any aggressive behaviors. It does not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient mental health admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an acute inpatient mental health admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri capsule 137mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare guidance says non-injectable, self-administered drugs like the Gocovri capsule 
are covered by the pharmacy (drug) benefit. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gocovri capsule 137mg for 
the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 9, 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 did not bill 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 code 72120 
is a column II code to column I code 72082. 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 imaging services provided to the enrollee on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the urgent care services provided on September 
14, 2021. 
 
You asked the Plan to waive the copay for the services provided. You say that you were not aware of this fee. 
The Plan denied your request. The Plan says the copay was correctly assessed. 
 
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 $65 
copay for each visit for urgently needed services.  
 
You have been asked to pay a $65 copay for the services provided. The services fall within the urgently needed 
services 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 copay for the urgent care services provided on September 14, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 there are no identifiable skilled nursing 
service needs. While there are identifiable skilled therapy service needs, these services are not required skilled 
nursing or therapy services on a daily basis. In conclusion, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).