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

 
We decided that the Plan does not have to pre-approve an MRI of the brain to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an MRI of the brain. The Plan denied your request. The Plan says an MRI of 
the brain is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an MRI of the brain to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 28, 2023, to 
March 7, 2023. 
 
You asked the Plan to pay for the medication. You say that you stayed overnight at the hospital and were given 
your maintenance drugs as you were instructed to leave all medication at home. The Plan denied your request. 
The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 provided 
from February 28, 2023, to March 7, 2023.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network home laboratory monitoring 
provided from April 09, 2022, to August 16, 2022. 
 
You asked the Plan to waive the copayment for an in-network home laboratory monitoring. You say that you 
have never had to pay a copayment for your provider to read your prothrombin time test (PT)/INR. You should 
not owe this amount. 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 $25 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You had three readings, resulting in a $75 copayment ($25 x 3 = $75). 
 You have been asked to pay a $75 copayment for an in-network home laboratory monitoring. This item/service 
falls within the Physician/Practitioner services, including doctors office visits 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 home laboratory monitoring provided from April 09, 
2022, to August 16, 2022.
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 you have had a recent decline in speech and 
mobility. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
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. 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. 
 
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 an additional unit of procedure code 99458 rendered on 
February 28, 2023. 
 You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says while the documentation does support that excess units were provided, the provider has 
not given any specific rationale for why the additional units needed to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
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 additional unit. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the review has 
determined that the provider did not document any medically necessary reason for performing extra units in 
excess of the 3 allowed. 
 
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 additional unit have not been met. Therefore, we decided that the Plan does 
not have to pay for an additional unit of procedure code 99458 rendered on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on January 11, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the vision services. You say that you are out-of-network, but the services were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 did not pre-approve the 
vision services. We found no exception that would require the Plan to pay for the vision services. Therefore, we 
decided that the Plan does not have to pay for the vision services provided on January 11, 2023, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing performed on August 2, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered because the patient has had genetic testing in the 
past. 
 
The Plan must follow Medicare rules. Medicare rules say that that BRCA testing is limited to once-in-a-
lifetime. If a patient has been previously tested for BRCA1 and BRCA2, repeat testing is not reasonable and 
necessary and will not be covered by Medicare. 
 
Records show that the patient had genetic testing in 2016 that included BRAC1 and BRAC2 analysis, so the 
genetic testing at issue here would be a second instance of this analysis.  Medicare does not cover this testing 
more than once in a lifetime for a patient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing performed on August 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 15, 2022, to July 
14, 2022. 
 
You asked the Plan to pay for the home health services. You say that the Plan should consider reversing the 
payment reduction.  The Plan denied your request. The Plan says you did not provide a valid Plan of Care for 
this patient for the 60-day certification period.  As a result, the claim was paid at the 30-day payment rate. 
 
The Plan must follow Medicare rules. Medicare rules say that home health providers must supply a Plan of 
Care for each patient.  In this case, although you provided medical records, you did not submit a Plan of Care 
for the 60-day period (i.e., June 15, 2022-August 13, 2022). Although the pages of the record indicate 'Plan of 
Care', no such Plan can be found within the record.  That is why the Plan was justified in only paying the 30-
day rate for these services. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 15, 2022, to July 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on July 10, 2022.  
You asked the Plan to pay for the ambulance service, conventional air services, transport and air mileage. You 
say that the emergency ambulance transport was medically necessary. The Plan denied your request. The Plan 
says after reassessing the entire clinical situation, information provided at the time of the appeal does not 
support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 service, conventional air 
services, transport and air mileage. Our reviewer says that the air ambulance services were not medically 
necessary. Our physician reviewer found there appear to be multiple closer facilities. There is no 
documentation noting a medically necessary reason for the enrollee to have been flown to a more distant 
facility. 
 
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 service, conventional air services, transport and air mileage have 
not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, conventional air 
services, transport, one way and air mileage provided on July 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on November 3, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that the modifier billed was valid. 
The Plan denied your request. The Plan says you billed this claim with an inappropriate modifier. 
 
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 3, 2022. 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-transport ambulance services provided on 
November 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services and air mileage 
provided on August 17, 2022. 
 You asked the Plan to pay for the ambulance service, conventional air services and air mileage. You say that 
the enrollee had a time sensitive condition with a cerebral vascular accident (CVA) needing emergent access to 
interventional neurosurgery. You also say that it was a reasonable and medically necessary request for air 
ambulance transfer. The Plan denied your request. The Plan says after reassessing the entire clinical situation, 
information provided at the time of the appeal does not support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 service, conventional air 
services and air mileage. Our reviewer says that the air ambulance services were not medically necessary. Our 
physician reviewer found the case file does not contain clinical documentation supporting that the transferring 
hospital, which is a primary stroke center, did not have adequate facilities to provide the medical services 
needed by 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 the ambulance service, conventional air services and air mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, conventional air services 
and air mileage provided on August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2022, to July 
25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
DRG should be paid as billed. The Plan denied your request. The Plan says the billed secondary diagnosis of 
J96.01 (acute respiratory failure with hypoxia) is not supported by the medical records. As a result, a lower 
DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis of J96.01 (acute respiratory 
failure with hypoxia). 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the billed secondary diagnosis of J96.01 (acute 
respiratory failure with hypoxia) is not supported in the medical record. Our physician reviewer found the 
member is a 70-year-old female with a past medical history including hypertension, liver disease and chronic 
lung disease who was admitted to the hospital with shortness of breath. She was treated with diuretics in the 
emergency department with improvement in symptoms. There was no evidence of persistent hypoxia or 
significant alterations in carbon dioxide levels. The documentation does not indicate the member had low 
oxygenation, respiratory distress, altered mental status or labored breathing. There were no laboratory values 
that were consistent with this diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 21, 2022, to July 25, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 2, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the patient had been discharged from the 
sending facility, so separate payment is allowed. The Plan denied your request. The Plan says this ambulance 
service is covered as part of the patient's hospital stay and no separate payment is warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that if a hospital inpatient is transferred to another 
facility temporarily for care, and then returns to the original hospital, that transportation is considered part of 
the stay and no separate payment is allowed. 
 
In this case, it does not appear as though the patient was formally discharged from the sending facility.  The 
patient was never admitted to the second facility either. The billing records indicate that the patient remained in an inpatient status at the sending facility and that is reflected in the hospital's bill. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test,  periodontal scaling and 
root planing, gingival irrigation, and drugs or medicaments dispensed in the office for home use 
(D0431,D4342, D4921, D9630) provided on March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test,  periodontal scaling and root planing, gingival irrigation, and drugs or 
medicaments dispensed in the office for home use (D0431,D4342, D4921, D9630) provided on March 16, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (code 93970) provided on 
February 14, 2023. 
 
You asked the Plan to pay for the scan. You say that this is not a duplicate. The Plan denied your request. The 
Plan says only one unit of this code can be billed per day. 
 
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 includes evidence that the items/services at issue were 
reimbursed by the Plan on March 16, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (code 93970) provided on 
February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation and cone beam 
computed tomography (CT) scan (D0180, D0367) provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial, and the services were medically necessary. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation and cone beam computed tomography (CT) scan (D0180, D0367) 
provided on November 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health aide services. You say that you live alone and need 
someone to help you bathe and get dressed since you cannot do that by yourself. You also say that you need 
help buying your groceries and cooking. The Plan denied your request. The Plan says the aide service you 
requested is to help with your personal care or housekeeping needs. The requested service does not meet the 
Medicare requirements for coverage. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
home health aide services.