Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
services 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 an emergency department visit provided on June 12, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed to consult with the dentist because 
you needed to know if the root canal would solve the issue. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 the Plan paid for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) on 
April 25, 2023; therefore, your benefit for the requested items or services was exhausted on the date of service 
of April 25, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) and the intraoral radiographic image (D0220) provided on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22514).  

You asked the Plan to pre-approve L3 kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 L3 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of bracing for fracture 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
18, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were not informed that you were not covered 
by the Plan for the evaluation, and you would have refused it. 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 the Plan paid for a comprehensive oral evaluation (D0150) on May 10, 2021; therefore, your benefit for 
the requested item or service was exhausted on the date of service of May 10, 2021. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0426) and ground mileage (A0425) 
provided on February 21, 2022. 
 
You asked the Plan to pay for ambulance services (A0426) and ground mileage (A0425). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says in the absence of clinical 
information, medical necessity and coverage cannot be determined.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 ambulance services (A0426) and 
ground mileage (A0425) have been met. The missing documents include medical and clinical records. Without 
these records there is no way to adequately review the appeal. Therefore, we decided that the Plan does not 
have to pay for ambulance services (A0426) and ground mileage (A0425) provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator . You say that the records provided support the need for 
the item in dispute. The Plan denied your request. The Plan says the request for continued use of a device to 
assist with breathing coded as E0466 does not meet the requirements for approval.  
 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the continued use of a home 
ventilator is not medically necessary. This enrollee has diagnoses of obesity hypoventilation syndrome, 
obstructive sleep apnea, chronic kidney disease, and coronary artery disease. The enrollee was prescribed a 
home ventilator in February 2023. COPD is mentioned in a progress note in February, but this is not a listed 
diagnosis for the enrollee, and there are no pulmonary function tests to confirm airways obstruction and assess 
severity. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The records do not 
indicate that the enrollee has been tried on BiPAP with average volume assured pressure support (AVAPS) as 
an outpatient. Medicare does not cover a home ventilator for the treatment of obesity hypoventilation 
syndrome, or when used at settings that can be provided 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee presented with profound 150-pound 
unintentional weight loss. Negative workup to date including a colonoscopy on August 22, 2022. The exam is 
reasonable and should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the vertical bitewings (D0277). We decided that the Plan does not 
have to pay more for the periodic oral evaluation (D0120) and the cleaning (D1110).  
 
You asked the Plan to pay more for a periodic oral evaluation (D0120) and a cleaning (D1110) and to pay for 
the vertical bitewings (D0277) provided by an out-of-network provider on May 11, 2023.. You say that that 
your coverage has a $0 copayment for dental services out-of-network, and they should cover it fully. The Plan 
says that you are responsible for any charged amount above the Plans cost-sharing amount when your services 
are received from an out-of-network provider. Also, the vertical bitewings are not covered by the Plan. 
 
We decided that the Plan has to pay for the vertical bitewings (D0277).  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, coinsurance, and benefit limitations). Your contract with the Plan does not say in 
clear and accurate terms what type of bitewings are covered.  
 
We looked at your contract with the Plan. We did not see where the contract says only a specific type of 
bitewing is covered. The Plan contract clearly say that bitewing x-rays are covered. This means that the Plan 
did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan 
has to pay for the vertical bitewings (D0277).  
 
We also decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and the 
cleaning (D1110). 
 
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 more for the periodic oral evaluation (D0120) and the cleaning (D1110). 
 
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 pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you need a routine 
cleaning every 6 months. The Plan denied your request. The Plan says the routine transportation services 
benefit has been exhausted. 
 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 a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on 
January 25, 2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the ambulance just came 
to make sure that you were alright. The Plan denied your request. The Plan says the services are not covered if 
there is no transport. 
 
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 January 25, 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 the ambulance services without transport received 
on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 2, 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 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 March 28, 2023. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings (D2391, D2331, D2335) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 November 16, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings (D2391, D2331, D2335) provided 
on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 29, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95250 and 99215 rendered on April 24, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 95250: 
 
Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum 
of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor 
placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording  
CPT 99215: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using time 
for code selection, 40-54 minutes of total time is spent on the date of the encounter 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support either code, as there is no documentation of any glucose monitoring. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95250 and 99215 rendered on April 24, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 26, 2023, to May 
30, 2023. 
 You asked the Plan to pay for the home health services. You say that the enrollee was not on hospice during 
this period. 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 home health services provided from May 26, 2023, to May 
30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation over the 24 visit limit. You say that you 
need the transportation to make it t all of your remaining appointments. The Plan denied your request. The Plan 
says the routine transportation services benefit covers up to 24 one-way trips per year and additional trips will 
not be covered. 
 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 a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.