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

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 
25, 2022. 
 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, 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 the computed 
tomography (CT) scan provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on July 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries are given a purchase option for 
durable medical equipment after the 10th month of renting the equipment. 
 
We looked at the file and Medicare rules. The file shows that you purchased the CPAP device directly without 
a rental period. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the continuous positive airway 
pressure (CPAP) device purchased on July 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on December 25, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that you believe that because this was the only 
location you could go to on this date for a COVID-19 test, that this should be covered. You also say that you 
were not able to get a doctor to order one for you. The Plan denied your request. The Plan says Medicare will 
not cover reimbursements of this test or the over-the-counter test. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the COVID-19 test provided on December 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen/supplies provided to the enrollee on 
January 6, 2022. 
 
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 denial of oxygen and supplies was appropriate. 
 
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 procedure code A0422 is not supported in the medical record. Specifically, it is not appropriate to 
report ambulance oxygen and supplies separately from the base payment for ambulance services. The payment 
for these supplies is included in the base rate for ambulance services. 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 oxygen/supplies provided to the enrollee on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 5, 
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 billed service is not 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. 
 
In this case, the CPT Code Manual definition of code 27446 is "arthroplasty, knee, condyle and plateau; medial 
OR lateral compartment." 
 
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 provider reported services 
performed by a RNFA (Registered Nurse First Assistant). In this case, "RNFAs are not credentialed by 
Medicare, so you would not bill or expected to be paid for their work by the Medicare Advantage Contractor 
(MAC)."  
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 surgical services provided to the enrollee on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 22, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says providers must not 
unbundle services. 
 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 looked at the file and the rules. We find that the gene panel was billed with multiple codes. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on November 22, 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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document the enrollee is very limited functionally, 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. Records do not document that services in the home with home health care or in a long-term care facility 
on a part time basis are not 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you believe the additional mileage should 
be covered under your Plan. The Plan denied your request. The Plan says you are requesting an additional 42.8 
miles for a total of 92.8 miles and your benefit only allows 50 miles. The Plan also says you have exceeded 
your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 60 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens are received from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 11, 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 Current Procedural Terminology (CPT) code 12041 remains not 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. 
 
In this case, the CPT Code Manual definition of code 12041 is "Repair, intermediate, wounds of neck, hands, 
feet and/or external genitalia; 2.5 cm or less." 
 
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 procedure report documents 
"Suture technique: Simple interrupted; Number of sutures: 5; Approximation: Close." In this case, the 
procedure report does not support intermediate repair to include wounds requiring layered closure of one or 
more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin 
(epidermal and dermal) closure."  
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 surgical services provided to the enrollee on April 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles to non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional miles. You say that this is medically necessary. The Plan 
denied your request. The Plan says trips over the 50 mile limit are denied. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when up 50 miles one-way.  
 
Additional mileage above 50 miles is not covered supplemental benefit with this plan. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional miles to non-emergency 
transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on December 29, 2021 and 
December 30, 2021. 
 
You asked the Plan to pay for the drugs. You say that you don't know why all the required medications were 
denied. The Plan denied your request. The Plan says this is not a covered 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 pay for self-administered drugs received 
on December 29, 2021 and December 30, 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 you received oral medications, had stable vital 
signs and received IV vancomycin during dialysis. You were at a contact guard assist level for functional 
mobility including gait to 60 feet. You do not require skilled nursing or therapy services on a daily basis. You 
do 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical (portable) ventilator. You say that the requested device 
is medically necessary. The Plan denied your request. The Plan says the requested device does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home mechanical (portable) 
ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found you 
have COPD, although results of pulmonary function tests are not provided. There have been repeated 
hospitalizations for hypercarbic respiratory failure. You may benefit from bipap, with or without AVAPS, 
during sleep. But there is no failure of bipap as an outpatient. Medicare does not pay for a home ventilator 
when used as bipap. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical (portable) ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided January 18, 2022.  
You asked the Plan to pay for the fundus photography. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
Though the Plan offers vision benefits in excess of Medicare coverage, the fundus photography is not among 
those covered services. Therefore, we decided that the Plan does not have to pay for the fundus photography 
with interpretation and report (92250) provided January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided to the enrollee on November 
19, 2021. 
 
You asked the Plan to pay for the services. You say that you were told authorization was not required. The Plan 
denied your request. The Plan says authorization was required for out-of-network services. 
 
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 acupuncture services provided to the enrollee on 
November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader. You say that the enrollee needs this glucose 
monitor to check his blood sugar 4 times per day and to assist in controlling his diabetes. The Plan denied your 
request. The Plan says the requested continuous glucose monitor is not medically necessary according to 
Medicare coverage rules. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 reader.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus Solution. 
 
You asked the Plan to pre-approve Ocrevus Solution. You say that the requested drug is medically necessary 
for the enrollee. You say that Ocrevus is the most appropriate treatment option for the enrollee to reduce 
disability, effectively decrease relapses, and delay disability progression. The Plan denied your request. The 
Plan says the enrollee has not tried the preferred agent and has not provided rationale for use of the non-
preferred product for safety or efficacy.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ocrevus Solution. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of 
Kesimpta before they will approve the requested drug, Ocrevus. There is no indication that the enrollee has 
tried and failed the required drug. There is no indication that the plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus Solution have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ocrevus Solution.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010) on 
tooth #11, #13, #22, #27 and a custom fabricated abutment (D6057) on tooth #11, #22, #27. 
 
You asked the Plan to pre-approve a surgical placement of an implant body and a custom fabricated abutment. 
You say that you were under the impression that they would be billing this differently. You say that you have 
dentures, but they are very painful and do not stay in your mouth while talking or eating. You also say you do 
not have teeth on the top and you need these procedures done. The Plan denied your request. The Plan says you 
have exhausted your maximum benefit for these 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. The Plan covers a surgical 
placement of an implant body and a custom fabricated abutment twice per calendar year. 
 
 
 
 We looked at the file and Medicare rules. The records show that you received 2 surgical placements of an 
implant body and 2 custom fabricated abutments on May 23, 2022, therefore, you have exhausted your 
maximum benefit for these service Based on this information, we decided that the Plan's rules for coverage of a 
surgical placement of an implant body and a custom fabricated abutment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010) on tooth 
#11, #13, #22, #27 and a custom fabricated abutment (D6057) on tooth #11, #22, #27.