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

 
We decided that the Plan does not have to pre-approve 24 non-emergent transportation trips. 
 
You asked the Plan to pre-approve the non-emergent transportation trips. You say that the services are 
medically necessary for you. The Plan denied your request. The Plan says you do not meet the criteria for 
approval. 
 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 members are diagnosed with both diabetes and congestive 
heart failure and need non-emergent transport services. 
 
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. Therefore, we decided that the 
Plan does not have to pre-approve 24 non-emergent transportation trips.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a CT scan.. The Plan denied your request. The Plan says that the enrollee 
does not meet the guidelines for this service. 
 
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. Our reviewer says that you 
need this medical item. Our physician reviewer found the enrollee meets all current criteria for LDCT scan for 
lung cancer screening. 
 
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. have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you are requesting reimbursement for the custom 
orthotics, and you exhibit many of the same symptoms as a diabetic. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code E0781 for date of service May 
11, 2023. 
 
You asked the Plan to pay for the supplies. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the items billed are not supported.  

The Plan must follow Medicare rules. Medicare rules say that claim lines billed for external infusion pump 
supplies billed without a KX modifier will be rejected as missing information for claims submitted on or after 
March 1, 2023 for all codes. 
 
We looked at the file and Medicare rules. Review of the file shows that the supplies billed with code E0781 
was not billed with the appropriate KX modifier. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
supplies billed with code E0781 for date of service May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture provided on June 27, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a covered benefit, and the 
Plan has reimbursement you before. The Plan denied your request. The Plan says acupuncture is only covered 
to treat CLBP. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, services at issue were not used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (left knee). 
 
You asked the Plan to pre-approve a genicular nerve block (left knee). You say that the injection is medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is not enough medical evidence 
that shows the procedure is helpful and safe for knee pain. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for any items or services that 
are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. The determination of medical necessity must be tailored to the 
individual patient and their unique clinical scenario. 
 
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 genicular nerve block (left knee). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. Further studies are needed to corroborate that the use of genicular nerve 
blocks are as safe and effective as standard treatment modalities. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 genicular nerve block (left knee) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a genicular nerve block (left knee).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs medicaments (D9630) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were assured that the procedures would be 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because prescription drugs or pre-medications are not covered by the Plan. 

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. 
 
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 the drugs 
medicaments (D9630) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on March 28, 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 Plan's 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 drugs or 
medicaments dispensed in the office for home use (D9630) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120), intraoral-periapical first 
radiographic image (D0220), intraoral-periapical each additional radiographic image (D0230), bitewings 
(D0274) and periodontal maintenance (D4910) provided on April 6, 2023. 
 
You asked the Plan to pay for intraoral-periapical first radiographic image, intraoral-periapical each additional 
radiographic image and periodontal maintenance . You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered 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. 
 
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 intraoral-
periapical first radiographic image (D0220), intraoral-periapical each additional radiographic image (D0230), 
and periodontal maintenance (D4910) provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 20, 2023, and billed with codes 87640, 87481, 87653, 87798, and 87088. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on January 20, 2023, and billed with codes 87640, 87481, 87653, 87798, and 87088.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7310 and D9223). 
 
You asked the Plan to pre-approve the dental services (D7310 and D9223). You say that you would like to 
request reconsideration of the denied dental services and that the services requested are medically necessary. 
The Plan denied your request. The Plan says the dental service codes requested D7310 and D9223 are not 
covered 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 pre-approve the 
dental services (D7310 and D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on May 16, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that the shingles vaccine is a Part D drug that isn't 
covered under the enrollee's Health Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on May 
16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
21, 2023. 
 
You asked the Plan to pay for the ED services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 21, 2023.
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 inpatient rehabilitation facility services are 
medically necessary for the full improvement of the enrollee. The Plan denied your request. The Plan says the 
services the enrollee requires can be provided in a different setting or at home with home health services.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on September 2, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the ED services 
provided on September 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), resin-based composite - three 
surfaces, anterior (D2332), inhalation of nitrous oxide/analgesia, anxiolysis (D9230),  and periodic oral 
evaluation - established patient (D0120) provided on June 27, 2023, and July 14, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), bitewings - 
four radiographic images (D0274), resin-based composite - three surfaces, anterior (D2332), inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230),  and periodic oral evaluation - established patient (D0120) 
provided on June 27, 2023, and July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 26340-AS, RT, 25259-AS, RT, 4 units of 
26442-AS, 25259-RT, and 26340-RT billed for date of service August 11, 2022. 
 
You asked the Plan to pay for procedure codes 26340-AS, RT, 25259-AS, RT, 4 units of 26442-AS, 25259-RT, 
and 26340-RT. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
payment for code 25259-RT is bundled into payment for code 25280. The Plan also says that the assistant 
surgeon services are not payable. 
 
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 25259 
is a column II code to column I code 25280. This claim has not been billed with an appropriate modifier to 
bypass the edit. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon 
services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology 
(CPT) codes 25259 and 26442. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this 
procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and 
will not be paid. Code 26340-AS was not billed with an appropriate anatomical modifier. This means this code 
is not payable as billed. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 26340-AS, RT, 25259-AS, RT, 4 units of 26442-AS, 25259-RT, and 
26340-RT billed for date of service August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (K1034) provided on July 12, 2023. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this item was medically necessary. The Plan 
denied your request. The Plan says over-the-counter COVID-19 tests are no longer a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that starting on May 12, 2023, Medicare no longer 
covers or pays for over-the-counter COVID-19 tests for those with Medicare Part B benefits. 
 
We looked at the file and Medicare rules. This test is no longer covered. Based on this information, we decided 
that Medicare rules for coverage of the COVID-19 testing have not been met. Therefore, we decided that the 
Plan does not have to pay for COVID-19 testing (K1034) provided on July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthrotomy (27310), removal of implant (20680), 
and insertion of a drug-delivery implant (11981) provided on June 22, 2023. 
 
You asked the Plan to pay for the surgical services. You say that this was the only available assistant at the 
time of the procedure. You say that the services were specifically requested by the in-network primary 
physician and in-network facility. The Plan denied your request. The Plan says the provider in this case is not 
eligible for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the knee arthrotomy (27310), 
removal of implant (20680), and insertion of a drug-delivery implant (11981) provided on June 22, 2023.
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 services are medically necessary for 
the enrollee to get the continuation of care needed. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan.  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.