Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a follow up visit provided on April 25, 
2023. 
 
You asked the Plan to waive the copayment for a follow up visit. You say that this was a surgical follow up and 
should not have a copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 $45 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $45 copayment for a follow up visit. This item/service falls within the 
Physician/Practitioner services, including doctors officevisits 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 a follow up visit provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and hard tissue 
regeneration (D4265), infiltration of sustained release therapeutic drug (D9613), bone replacement graft 
(D7953) and guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve these dental services. You say that these are medically necessary. The Plan 
denied your request. The Plan says these are not 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and hard tissue regeneration (D4265), infiltration of sustained release 
therapeutic drug (D9613), bone replacement graft (D7953) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
periapical first radiographic image (D0220), and the intraoral-periapical additional radiographic images  
(D0230 x 5) provided on April 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
  
 
 
 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, one intraoral x-ray is covered per calendar year. On this day, one intraoral radiographic image 
provided was paid for by the plan. Therefore, you have exhausted the allowable benefit for this service. The 
subsequent intraoral radiographic images provided in this case are not eligible for coverage. Therefore, we 
decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
periapical first radiographic image (D0220), and the intraoral-periapical additional radiographic images  
(D0230 x 5) provided on April 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was dispatched to your home due to slurred and garbled speech, and loss or near loss of 
consciousness. You also say that upon assessment and treatment a decision was made to not go to the  hospital. 
The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 The ambulance company did not provide transport services on February 4, 2023. 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 provided on February 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (scooter) 
(K0800). 
 
You asked the Plan to pre-approve a scooter. You say that having a scooter would really help you relieve the 
pressure on your bad knee until you have the knee surgery and are recovered. The Plan denied your request. 
The Plan says given the provided documentation, you do not meet the guidelines for the requested service 
which does not appear medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 scooter. Our reviewer says that you 
do not meet the criteria for coverage. Our physician reviewer found you do not require a powered mobility 
vehicle to perform MRADLs in the home. Our reviewer also found that you are functioning independently with 
a walker in the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 standard power operated vehicle (scooter) (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network magnetic resonance imaging 
(MRI) of the spine. 
 
You asked the Plan to waive the copayment for an MRI. You say that this is too costly, and you cannot afford 
it. The Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $233.46 which is less than the $300 copayment for an MRI. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an in-network magnetic resonance imaging 
(MRI) of the spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive the care needed to return to their prior level of function. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on February 28, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service should be covered. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 20, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
care provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 23, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the nursing facility care provided on May 23, 
2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the Intracept procedure. 
 
You asked the Plan to pre-approve  the Intracept procedure . You say that the enrollee's chronic low back pain 
due to degenerative disc disease has resulted in the development of vertebrogenic pain.  The Plan denied your 
request. The Plan says the Intracept procedure is not medically necessary. The Plan says the Intracept 
procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  the Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 23, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was underpaid. The Plan denied 
your request. The Plan says no records were received to verify services. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance services have been met. 
medical records. Therefore, we decided that the Plan does not have to pay for ambulance services provided on 
December 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transportation ambulance services received on April 8, 
2023. 
 
You asked the Plan to pay for the non-transportation ambulance services. You say that you have never been 
charged for ambulance services before. The Plan denied your request. The Plan says if there is no transport 
then there is no Medicare covered Service. 
 
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 April 8, 2023. 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 non-transportation ambulance services received on 
April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service October 15, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the level of care billed. 
The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The medical 
records don't support a detailed interval history or medical decision making of high complexity. 
 
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 99233 is  subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. 
 
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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee is a 77-year-old man who presented to the 
emergency room with lumbar radiculopathy and acute kidney injury.  In this case, the documentation supports 
a detailed exam, but not a detailed history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service October 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and outpatient intravenous (IV) 
insulin therapy (OIVIT) services provided on March 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication.  
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically 
reasonable and necessary, and therefore are not covered. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. 
 
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 99214 is a column II code to column I code 
96365. 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 office visit (99214) and outpatient intravenous (IV) insulin therapy (OIVIT) services provided on 
March 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Dexamethasone sodium phosphate, 
famotidine, pemetrexed, and carboplatin. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee has stage 3 non-small cell lung cancer 
and will be receiving this chemotherapy regimen after their surgery.  The Plan denied your request. The Plan 
says Keytruda, Dexamethasone sodium phosphate, famotidine, pemetrexed, and carboplatin are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use. 
 
  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 drugs. Our reviewer says that 
Keytruda, Dexamethasone sodium phosphate, famotidine, pemetrexed, and carboplatin are not medically 
necessary. Our physician reviewer found that the requested use of Keytruda, Dexamethasone sodium 
phosphate, famotidine, pemetrexed, and carboplatin are not FDA-approved. The drugs are also not supported 
by one of the major drug compendia or by clinical research. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda, Dexamethasone sodium phosphate, famotidine, pemetrexed, and carboplatin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care billed for dates of service 
December 14, 2022, to December 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should be billed as secondary payer. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on January 1, 2023. A comparison of the two claims shows these are exact duplicates. Based on this 
information, we decided that the Medicare rules for the billed services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care billed for dates of service December 
14, 2022, to December 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 the driving distance for a one-way trip is within 50 miles.  
 
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, the provider is 
located 76 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.