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

 
We decided that the Plan has to pay for inpatient hospital services provided on November 25, 2021, through 
December 21, 2021, and billed with diagnosis code A02.1. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code A02.1 is supported by the records. The Plan denied your request. The Plan says that 
the Salmonella infection was not present at the time of admission is erroneous. 
 
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 code A02. 1-Salmonella sepsis. 
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 diagnosis code of A02.1 - salmonella sepsis - is supported in the 
record. Our physician reviewer found the member presented with weakness, confusion, and anorexia. While 
still in the emergency department, the member developed a fever. Blood cultures were drawn, and antibiotics 
were initiated. These blood cultures grew Salmonella. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on November 25, 2021, through December 21, 2021, and billed with diagnosis code 
A02.1.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a bed lift kit purchased on October 4, 
2022. 
 
You asked the Plan to provide reimbursement for a bed lift kit. You say that you were not told a prior 
authorization was required. The Plan denied your request. The Plan says that this item was not authorized, and 
it was not supplied by a Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The Plan contract says that prior authorization is required for DME and 
related supplies. 
 A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. We found no exception that would require the Plan to provide reimbursement for the bed lift kit. 
Therefore, we decided that the Plan does not have to provide reimbursement for a bed lift kit purchased on 
October 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93312 and 93325 billed for date of service 
February 10, 2022. 
 You asked the Plan to pay for procedure codes 93312 and 93325. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says payment for code 93312 is bundled into 
payment for code 01926. The plan also says procedure code 93325 is an add on code and cannot be billed 
without a valid primary procedure code. 
 
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 93312 
is a column II code to column I code 01926. This claim has not been billed with an appropriate modifier to 
bypass the edit. Procedure code 93325 is an add on code to 93312 and cannot be paid. 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 93312 and 93325 billed for date of service February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of the prostate is 
covered when specific criteria are met. 
 
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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the transurethral waterjet ablation of the 
prostate at issue in this case meets all of Medicare's LCD criteria for medically reasonable and necessary for 
the enrollee. Provided records in this case document the enrollee has known prostate cancer with no evidence 
the enrollee has had a negative prostate biopsy within the last 6 months. This factor is exclusionary based on 
rules in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a broken maxillary complete denture base 
provided on January 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this was a covered benefit. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 the repair 
of a broken maxillary complete denture base provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field assessment provided on August 21, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the visual field assessment. You say that this assessment was medically 
necessary. The Plan denied your request. The Plan says that this service was 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 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 a visual field assessment provided on August 21, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON physician visits. You say that the enrollee received are due ot her 
multiple chronic conditions. You say that the requested OON provider is able to provide her with care within 
the facility, as they are contracted with the Assisted Living facility. The Plan denied your request. The Plan 
says the requested services are available in the network. The Plan says that the enrollee is currently receiving 
care from a contracted primary care provider in the facility. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physician visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
21, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support provided on June 
7, 2022. 
 You asked the Plan to pay for the ambulance service. You say that you are wheelchair bound and your wife 
cannot get you out of the house due to not having a ramp. You also say you had back surgery on June 4, 2022 
and were admitted from the emergency room to the hospital due to high blood pressure and COVID-19. The 
Plan denied your request. The Plan says the ambulance transport was not medically necessary. 
 
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 .  
 
We looked at your request, the records in the case file, and the rules. The Plan states your appeal letter 
identified why personal transport would not be possible to get to the hospital (not able to get up from 
wheelchair and no wheelchair ramp out of house), but the ambulance records showed that they considered the 
transport mode to be non-emergent and the problem to just be weakness. This makes the ambulance transport 
provided non-emergency. 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 pay for ambulance 
service, advanced life support provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 19, 
2022 to April 25, 2022. 
 You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column II code to column I code 99233. 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 procedure code 99232 billed for date of service April 19, 2022 to 
April 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept provided on May 30, 2022. 
 
You asked the Plan to pay for the paramedic intercept. You say that you are a retired nurse and fully whole 
heartedly feel the urgency and need of paramedic care in instances such as this with a life threatening situation. 
The Plan denied your request. The Plan says this is a non-covered service. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept provided on May 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown - porcelain/ceramic (D2740) 
provided on January 26, 2023. 
 
You asked the Plan to waive the coinsurance for the crown - porcelain/ceramic. You say that you were not told 
that it was limited to what Medicare allowed. You also say you were expecting 50% of what the dentist billed 
to be covered and not 50% of what Medicare approved to be covered. 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 50% 
coinsurance for crowns when provided in and out-of-network.  
 
You have been asked to pay a 50% coinsurance, subject to the annual plan deductible for each visit for crowns 
- porcelain/ceramic. This item/service falls within the prosthodontics benefit category. The claim processed 
with your $100.00 deductible, and then the amount of $535.04 was processed with your 50% coinsurance 
responsibility of $267.52. The plan reimbursed you back $267.52. 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 
coinsurance for a crown - porcelain/ceramic (D2740) provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of a root canal obstruction; non-surgical 
access (D3331). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve treatment of 
a root canal obstruction; non-surgical access (D3331).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 27, 2022, 
through March 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was brought in by ambulance to the emergency department (ED) on February 27, 2022 
for an evaluation of weakness and dizziness. The enrollee had passed out in a chair and was having difficulty in 
ambulating, he had weakness in his left arm, and had a droopy mouth for approximately thirty minutes. 
Subsequently, the enrollee was diagnosed with syncope due to orthostatic hypotension and was admitted to the 
Telemetry Unit for further evaluation and treatment. The urinalysis was positive for leukocyte esterase, 
ketones, bacteria, and white blood cells. During the stay, the enrollee complained of weakness and tingling in 
the arms/legs in which he received treatment. The enrollee was discharged home on March 2, 2022. The review 
has determined that the record showed that at the time of the inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 27, 2022, through March 2, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vein x-rays (75820, 75822, 75825), selective catheter 
placement, venous system; first order branch (36011), selective catheter placement, venous system; second 
order, or more selective, branch (36012), intravascular ultrasound; each additional noncoronary vessel (37253), 
ultrasound guidance for vascular access (76937), moderate sedation services provided by the same physician or 
other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports (99152), and moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 
minutes intraservice time (99153). 
 
You asked the Plan to pre-approve multiple procedures of the veins in the lower extremity. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous stents are covered when specific criteria 
are met. 
 
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 multiple procedures of the veins in the 
lower extremity. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
the review has determined that the procedure on the enrollee's vein do not meet the coverage criteria detailed in 
the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple procedures of the veins in the lower extremity have not been met. 
Therefore, we decided that the Plan does not have to pre-approve vein x-rays (75820, 75822, 75825), selective 
catheter placement, venous system; first order branch (36011), selective catheter placement, venous system; 
second order, or more selective, branch (36012), intravascular ultrasound; each additional noncoronary vessel 
(37253), ultrasound guidance for vascular access (76937), moderate sedation services provided by the same 
physician or other qualified health care professional performing the diagnostic or therapeutic service that the 
sedation supports (99152), and moderate sedation services provided by the same physician or other qualified 
health care professional performing the diagnostic or therapeutic service that the sedation supports; each 
additional 15 minutes intraservice time (99153).