Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis, gangrene of second right toe, gastrointestinal bleeding and had partial amputation of right foot. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there
is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Apokyn for the enrollee.
You asked the Plan to pre-approve this drug. You say that the patient is already established on this medication and notes significant improvements in resolving symptoms brought on by episodes. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Apokyn for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve graft, bone; mandible (CPT code 21215, graft, bone; 
nasal, maxillary or malar areas (CPT code 21210), reconstruction of mandible or maxilla, endosteal implant 
(CPT code 21249) and sinusotomy, maxillary (antrotomy); intranasal (CPT code 31020) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that this is due to the enrollee having 
mandibular atrophy, which is a defect, causing the enrollee the inability to eat and open mouth wide. You state 
with the enrollee unable to open their mouth wide they are unable to put in dentures and then again unable to 
eat due to not having teeth. You state mandibular reconstruction with posts and bone graft will give the enrollee 
the ability to have a better quality of life. The Plan denied your request. The Plan says medical need has not 
been met because the enrollee's records do not show the dental services meet the criteria.

Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve 
graft, bone; mandible (CPT code 21215, graft, bone; nasal, maxillary or malar areas (CPT code 21210), 
reconstruction of mandible or maxilla, endosteal implant (CPT code 21249) and sinusotomy, maxillary 
(antrotomy); intranasal (CPT code 31020) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 24, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this provider is listed as an in-network provider 
on the Plan's website. The Plan denied your request. The Plan says out-of-network routine vision care is not 
covered by your vision benefit. 
 
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. The Plan covers eye refractions only when they are received from a provider who participates in the 
Plan's specified routine vision provider network. 
 
We looked at the file and the Plan's rules. The provider in this case does not participate in the Plan's specified 
routine vision network. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on February 24, 2021.  
 
Your complaint about potential confusion regarding your medical and supplemental vision networks is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81275, 81210, and 81235) provided on May 9, 2019.
You asked the Plan to pay for the laboratory services. 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services (81275, 81210, and 81235) provided on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety 
protocols for the provision of evaluation, treatment or procedural services during a public health emergency 
(99072) provided February 26, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that your medical records fully support and 
justify billing code 99072. Based on the information provided, please reprocess for prompt payment. The Plan 
denied your request. The Plan says the provider has not submitted any clinical records to support the medical 
necessity of the service. This service is considered incidental to the patient's total episode of care. 
 
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 find that CPT code 99072 is not 
supported in the medical records. Specifically, the records show that the Plan had requested medical records 
from the provider without success. CMS assigns a status code of B for this code which states that payment for 
covered services are always bundled into payment for other services not specified. This code cannot be paid as 
a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety 
protocols for the provision of evaluation, treatment or procedural services during a public health emergency 
(99072) provided February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Anesthesia for patient of extreme age, younger than 1 year
and older than 70 (99100) provided March 10, 2021.
You asked the Plan to pay for the anesthesia services. You say that please review the attachments in order to
process and reprocess your claim for reimbursement. The Plan denied your request. The Plan says payment for
this service is bundled into the primary procedure
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, CMS assigns a status code of B for
this code which states that payment for covered services are always bundled into payment for other services not
specified. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing
criteria have not been met. Therefore, we decided that the Plan does not have to pay for Anesthesia for patient
of extreme age, younger than 1 year and older than 70 (99100) provided March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron, 4 mg oral disintegrating tablet.
You asked the Plan to pre-approve ondansetron. You say that the medication is medically necessary. The Plan
denied your request. The Plan says the requested drug is considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 ondansetron, 4 mg oral
disintegrating tablet.
Benefits for ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a Coronavirus (COVID-19) test provided in
Aruba, on March 3, 2021.
You asked the Plan to reimburse you for the Coronavirus (COVID-19) test. You say that you traveled to Aruba
and it was a mandatory test to come back into the United States. The Plan denied your request. The Plan says
this test is an exclusion because the test was required in relation to foreign travel by a governmental body,
which is considered a third-party request and is not covered.
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to
examinations required by third parties such as insurance companies, business establishments, or Government
agencies.
We looked at the file and Medicare rules. Medicare says that the routine physical checkup exclusion applies to
examinations required by third parties such as insurance companies, business establishments, or Government
agencies. Therefore, we decided that the Plan does not have to reimburse you for a Coronavirus (COVID-19)
test provided in Aruba, on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and a cone beam image capture (D0380) provided on May 24, 2021.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you do not understand this denial. The Plan denied your request. The Plan says you already had a limited oral evaluation in 2021, which was covered by the Plan. Only one limited evaluation can be covered per plan year. In addition, the cone beam image capture is not covered by your dental benefit under any circumstances.
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.
Services not listed as eligible for coverage in the Plan's 2021 contract will not be covered. The Plan can cover one limited exam to evaluate a problem per plan year. 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 or are requested in a frequency that exceeds what is covered by this benefit. Documentation shows that the cone beam image capture is not listed as a covered service under your contract, and records show that you have had two limited oral exams in 2021, one of which was paid for and covered by the Plan. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and a cone beam image capture (D0380) provided on May 24, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November
21, 2020.
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 procedure code 99285 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 99285 is Level 5 emergency department visit for
evaluation and management of patient with problem immediately threatening life, including comprehensive
history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
the Level 5 complexity of services. 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 emergency
room (ER) services rendered on November 21, 2020.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the tenotomy and osteotomy. We decided that the Plan does not have to pay for tenotomy.
You asked the Plan to pay for the tenotomy and osteotomy. You say that you would like reconsideration based on the records submitted. The Plan says that the payment for these services is bundled with the payment of others.
We decided that the Plan has to pay for osteotomy.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 tenotomy and osteotomy. Our reviewer says that the documentation supports that a dorsal opening wedge osteotomy was made in the medial cuneiform, with insertion of a Synthes peek cotton wedge after inserting bone graft into the central cavity of the wedge. The documentation supports that this procedure was separate and distinct from the CPT code 29740. 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 osteotomy have been met. Therefore, we decided that the Plan has to pay for osteotomy.
We also decided that the Plan does not have to pay for tenotomy. 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 tenotomy. Our physician reviewer found the Operative Note does not contain documentation of a percutaneous Achilles tenotomy 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 tenotomy have not been met. Therefore, we decided that the Plan does not have to pay for tenotomy.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision represented by code 76376 provided on January 27, 2021.
You asked the Plan to pay for code 76376. 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 say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76376 has a bundled relationship with code 78227 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision represented by code 76376 provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided May 26, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you needed new x-rays prior to dentures. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 limited 
oral exam when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on March 10, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be improving and are expected to complete acute care services in the 
short-term which can be safely completed at the current acute care facility. There are no services at the LTACH 
that you require that are not already available and covered at the current facility. Transfer to a lower level of 
care may be considered when treatment has completed. 

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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided March 
22, 2021. 
 
You asked the Plan to waive the copayment for the emergency ambulance services. You say that the claim 
should be paid. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 $290 
copayment per date of service for ground ambulance and air ambulance.  
 
You have been asked to pay a $290 copayment for the emergency ambulance services. The emergency
ambulance service falls within the Ambulance 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 copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and 
ground mileage, per statute mile (A0425) provided March 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services represented by code 76705 provided on June 4, 2021.
You asked the Plan to pay for code 76705. 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 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 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 ultrasound services represented by code 76705 provided on June 4, 2021.