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

 
We decided that the Plan does not have to pay for Bupivacaine provided on January 4, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that the drug at issue has been billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the drug at issue is included in the global surgery 
payment for the procedure coded 20610 provided on the same date. Based on this information, we decided that 
Medicare rules for coverage of the drug at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for Bupivacaine provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoralcomprehensive series of radiographic images 
(D0210) provided on January 25, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental items provided has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the dental items provided was exhausted on April 5, 2021.   
 
Specifically, the Plans contract states that one set of intraoral-comprehensive series of radiographic images is 
covered every three years. You previously received these dental items on April 5, 2021, less than three years 
prior, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these items. 
Therefore, we decided that the Plan does not have to pay for the intraoralcomprehensive series of radiographic 
images (D0210) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two resin-based composites provided on November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these procedures because the initial 
provider did not properly cover your cavities. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 1, 2022. Therefore, 
we decided that the Plan does not have to pay for two resin-based composites provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service June 20, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that the denial of payment 
is incorrect. The Plan denied your request. The Plan says the codes are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, and 88360. This means 
there is both a professional and technical component for the CPT codes. In this case, an appropriate modifier to 
indicate the professional component has not been billed with the CPT codes. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88342, and 88360 billed for date of service June 20, 2022.
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 enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 7, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that physical therapy has greatly improved the 
enrollee's physical and emotional state. You say that physical therapy is the best option for the enrollee. The 
Plan denied your request. The Plan says the physical therapy services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our reviewer says 
that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee is 9 months post stroke and has not regained 
their full function. The enrollee has shown little change in response to therapy over the preceding two months 
as would be expected at this late date post stroke. Although the enrollee has a stable physical therapy program 
and can continue with a home exercise program, continued therapy is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on September 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 1, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you should not be charged two copays. The 
Plan denied your request. The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
   
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 
on January 1, 2023.  
 
Benefits for self-administered drugs 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on November 17, 2022. 
 You asked the Plan to pay for the ambulance services. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on November 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network skilled nursing facility 
(SNF) care provided on October 11, 2022, to October 31, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network skilled nursing facility (SNF) care. You say 
that you were not coherent at the time of admission to the SNF and was not given the choice. 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 50% 
coinsurance for SNF Care. 
 
You have been asked to pay 50% coinsurance for out-of-network skilled nursing facility (SNF) care. This 
item/service falls within the SNF Care 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. The total you owe is $6,862.04, which is 50% of the allowed amount for an out-
of-network SNF stay ($13,724.09 allowed x 50% = $6,862.04) Therefore, we decided that the Plan does not 
have to waive the coinsurance for out-of-network skilled nursing facility (SNF) care provided on October 11, 
2022, to October 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) services provided on February 27, 
2023. 
 You asked the Plan to pay for the ER services. You say that the enrollee was discharged from the emergency 
visit to home and the hospice evaluation was previously scheduled at the patients home. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency room (ER) services provided on February 27, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because they are 
receiving the care they need in the hospital where they are now and there is no need to transfer to the LTACH 
at this time. They can stay in the hospital until they are safe for transfer or discharge. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.   
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 LTACH services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis and a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and a CT scan of the thorax. You say 
that the enrollee was diagnosed with pancreatic cancer and has gone through neoadjuvant chemotherapy. You 
say that the enrollee will need close and continued radiological monitoring. The Plan denied your request. The 
Plan says that a CT scan of the abdomen and pelvis and a CT scan of the thorax is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis 
and a CT scan of the thorax. Our reviewer says that a CT scan of the abdomen and pelvis and a CT scan of the 
thorax is medically necessary. Our physician reviewer found that a chest CT with contrast every 3-6 moths for 
2 years and then every 6 months is recommended for surveillance. The enrollee is within the 2-year mark 
therefore the service is reasonable and medically necessary. 
 
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 CT scan of the abdomen and pelvis and a CT scan of the thorax have been 
met. Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis and a CT 
scan of the thorax.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent detection (87636), blood-oxygen testing 
(94761) and additional resources (99072) billed for date of service August 31, 2022. 
 
You asked the Plan to pay for infectious-agent detection, blood-oxygen testing and additional resources. You 
say that the services at issue have been billed correctly. The Plan denied your request. The Plan says the claim 
for the molecular pathology testing at issue did not include the required unique identifier. The Plan also says 
that procedure code 94761 is bundled into payment for code 94618. Procedure code 99072 is also considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-agent 
detection have not been met. 
 
Additionally, we have confirmed that code 94761 is a column II code to column I code 94618 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria for blood-oxygen testing (94761) have not been met. 
 
We also find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of additional resources (99072) have not been met.  
 
Therefore, we decided that the Plan does not have to pay for infectious-agent detection (87636), blood-oxygen 
testing (94761) and additional resources (99072) billed for date of service August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the appointment was made 6 months before you 
knew your dentist was leaving. You also say that you assumed the replacing dentist was still covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation - new or established patient was exhausted on date of 
service January 4, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation - new or established patient (D0150) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital clinic visit provided on 
February 23, 2023. 
 
You asked the Plan to waive the copayment for the hospital clinic visit. You say that your card says you have a 
$0 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 $10 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $10 copayment for the hospital clinic visit. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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. The record shows the provider utilizes 
hospital-based billing. Therefore, we decided that the Plan does not have to waive the copayment for the 
hospital clinic visit provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) services provided on 
November 3, 2022. 
  
You asked the Plan to pay for the ECG services. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the electrocardiogram (ECG) services provided on November 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the items were not medically necessary.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. It has not been 
established that a moist electric heating pad (E0215) or water circulating heat pad with pump (E0217) is 
reasonable and necessary compared to a standard electric heating pad (E0210); therefore, if code E0215 or 
E0217 is provided it will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are 
not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, 
regardless of how they are billed on the claim.  It has not been established that a water circulating heat pad with 
pump (E0217) is reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (E0675) and water circulating heat pad with pump (E0217).