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

 
We decided that the Plan does not have to pay for ambulance services without transport on September 29, 
2023. 
 
You asked the Plan to pay for ambulance services without transport. You say that you were talked out being 
transported to the emergency room by the Emergency Medical Technician (EMT). The Plan denied your 
request. The Plan says ambulance services without transport are never covered. 
 
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 September 29, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport on 
September 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that you are incapable of walking due to 
a serious injury. The Plan denied your request. The Plan says the Plan attempted to obtain supporting medical 
records but was not successful. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of semi-electric hospital bed have been met. No supporting medical records were submitted to demonstrate that this item is medically necessary and 
reasonable for you. The Plan attempted to obtain medical records, but none were submitted. Therefore, we 
decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on June 9, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing (0315U). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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. 
 
We looked at the file and Medicare rules. Per review of the DEX Diagnostic Exchange, the DecisionDx-SCC 
test was reviewed through the MolDX process and was found to not meet Medicare coverage criteria. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on 
June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-shape of bones (D7310), the general anesthesia 
(D9222), the general anesthesia (D9223 x3), the therapeutic drug injection (D9610) and the drug injection 
(D9612) provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the services 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 re-shape of bones (D7310), the 
general anesthesia (D9222), the general anesthesia (D9223 x3), the therapeutic drug injection (D9610) and the 
drug injection (D9612) are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the re-shape of bones (D7310), the general anesthesia (D9222), the general anesthesia 
(D9223 x3), the therapeutic drug injection (D9610) and the drug injection (D9612) provided on September 11, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs are custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs, and no identifiable skilled 
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 11, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the billed codes are correct. The Plan denied your 
request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that the panel testing at issue was billed using codes 87801, 87493, and 87798. We looked at the 
file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. 
There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. 
As such, a single code with one unit of service should be used. Based on this information, we decided that 
Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the panel testing billed for date of service July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim must be filed no later than the close of the period 
ending 1 calendar year after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until September 13, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. Your physician says that you are compliant with the 
noninvasive mechanical ventilator nightly, and the only time not worn is when there are any power outages. 
The physician also says that your hypercapnia has now been normalized with this treatment and has not been 
admitted with worsening respiratory failure.   The Plan denied your request. The Plan says a home ventilator is not medically necessary for the enrollee 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found you were compliant with 
AVAPS with auto titration but the following month compliance was 30%. You do have thoracic restrictive 
disease but no arterial blood gas to support resolution of hypercapnia nor failure of BiPAP with AVAPS. 
Hence, at this time, given the data and documentation provided, there is no support for the home ventilator and 
therapy may be delivered with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and home health skilled 
nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found documentation 
shows that the enrollee has had clinical and functional status change however there is no face-to-face visit 
designating the enrollee as home bound. The records do not show that the requested services are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy and home health skilled nursing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination (procedure 73502) provided on 
August 21, 2023. 
 You asked the Plan to pay for a radiologic examination (procedure 73502). You say that you are requesting the 
claim be reviewed and reprocessed for payment. The Plan denied your request. The Plan says modifier 50 is 
considered inappropriate for the procedure code billed. 
 
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 73502 is radiologic examination, hip, unilateral, with 
pelvis when performed; 2-3 views. 
 
We find that CPT code 73502 is not supported in the medical record. Specifically, that if there is a bilateral 
surgery indicator of 0, modifier 50 cannot be used. Based on this information, we decided that Medicare rules 
for coverage of a radiologic examination (procedure 73502) have not been met. Therefore, we decided that the 
Plan does not have to pay for a radiologic examination (procedure 73502) provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the mechanical traction therapy, the 
neuromuscular re-education, unlisted modality, and the ultraviolet therapy provided by a chiropractor on April 
26, 2023, to July 5, 2023. 
 
You asked the Plan to pay for the office visit, the mechanical traction therapy, the neuromuscular re-education, 
unlisted modality, and the ultraviolet therapy. You say that you assumed that the services would be covered 
because your previous chiropractic services were. The Plan denied your request. The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit, the mechanical traction therapy, the neuromuscular re-
education, unlisted modality, and the ultraviolet therapy provided by a chiropractor on April 26, 2023, to July 
5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybelsus. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 pre-approve Rybelsus.   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
images (D0220 and D0230), the bitewings (D0270), and a resin-based composite (D2391) provided by an out-
of-network provider on August 22, 2023, August 31, 2023, and September 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you could not find an in-network provider in 
time because you were going out of the country within a few days. 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. Also, it was verified prior to the dates of service you were advised that you have no out-of-network 
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 a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and D0230), the 
bitewings (D0270), and a resin-based composite (D2391) provided by an out-of-network provider on August 
22, 2023, August 31, 2023, and September 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81270, 81279, 81219, 81338, and G0452 
provided on July 24, 2023. 
 
You asked the Plan to pay for procedure codes 81270, 81279, 81219, 81338, and G0452. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
claim for this molecular pathology testing did not include the required unique identifier. Additionally, payment 
for code G0452 is bundled into payment for codes 81270, 81279, 81219, and 81338. 
 
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. Medicare 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. Additionally, we have confirmed that code G0452 is a column II code to column I codes 81270, 
81279, 81219, and 81338. This claim has not been billed with an appropriate modifier to bypass the edit. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 81270, 81279, 81219, 
81338, and G0452 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 81270, 81279, 81219, 81338, and G0452 provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (code D9310) provided on August 7, 2023. 
 
You asked the Plan to pay for a consultation. You say that the service should be paid. The Plan denied your 
request. The Plan says a consultation is a non-covered dental service. 
 
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 pay for a consultation 
(code D9310) provided on August 7, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (procedure 99284) provided on June 6, 
2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that you are 
requesting the claim be reviewed and reprocessed for payment. The Plan denied your request. The Plan says 
that the claim submitted is a duplicate and the provider was already paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan failed to submit documentation showing that two separate 
claims with procedure code 99284 were reported as being performed on the same day by the same provider. 
Therefore, we decided that the Plan has to pay for an emergency department visit (procedure 99284) provided 
on June 6, 2023.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 
7, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. 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. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on March 7, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0210) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous dental provider cancelled your 
appointment, the dentist left the practice, did not answer or return calls, and did not provide you with their 
records and x-rays. 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 September 13, 2021. 
Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0210) provided on August 
15, 2023.