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

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not enough evidence showing the requested device would improve 
the outcome for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a wireless pulmonary artery pressure 
sensor. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is a lack of clinical studies examining long-term 
clinical outcomes establishing the value of the CardioMEMS device. Therefore, the CardioMEMS system 
would not be considered medically appropriate and necessary in this patients clinical management.  
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 wireless pulmonary artery pressure sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supplies and 
accessories provided on August 9, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted the  
medical records and documents to review and overturn the denial. The Plan denied your request. The Plan says 
the service is not supported by the documentation submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that for any items that do not have proof of delivery 
from the supplier, such claimed items shall be denied. 
 
We looked at the file and Medicare rules. The record does not contain a valid description of the item(s) being 
delivered. Based on this information, we decided that Medicare rules for coverage of the CGM, supplies and 
accessories. have not been met. Therefore, we decided that the Plan does not have to pay for a continuous 
glucose monitor (CGM), supplies and accessories provided on August 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
April 10, 2023, through April 20, 2023.  
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 the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on April 10, 2023 with Bipolar 
Disorder, Current Episode Depressed, Dementia, and Alcohol Use Disorder. Based upon the review of the 
records provided, it was not expected that this enrollee would improve in a reasonable period of time as she did 
not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any 
aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or 
others. The health plans denial of inpatient psychiatric services appears appropriate. This enrollee did not 
appear to require inpatient mental health treatment as she was not a danger to herself or others and was 
cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking 
place. It did not appear that the services were reasonably expected to improve the enrollees condition or were 
for the purpose of a diagnosis. It did appear that the records were supervised and evaluated by a physician. 
Based upon the review of the records provided this enrollee does not meet criteria for coverage of the acute 
inpatient mental health treatment provided as she was not shown to be a danger to herself or others and did not 
have auditory or visual hallucinations. She was noted to be cooperative and compliant with treatment while not 
showing any aggressive behaviors. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from April 10, 2023, through April 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, 
including any pins when required (D2950), and endodontic therapy, molar tooth (excluding final restoration) 
(D3330) provided on June 19, 2023, to July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were diagnosed as needing a root canal and 
your dentist referred you to three endodontists. The first one was no longer practicing, the second one there was 
no answer and the third could not see me for three weeks I was in such pain, there is no way I could wait three 
weeks. 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 crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), and 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on June 19, 2023, to July 17, 
2023.  
 
Your complaint about your access to the network providers is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on April 11, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the enrollee was seen for acute onset weakness, headache, and dizziness. The enrollee was noted to have 
bradycardia and hypotension, but the bradycardia had resolved by the time they arrived at the emergency 
department (ED). Documentation supports an appropriate history/exam but not a high level of decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on April 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 27, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you want to appeal 
the amount being charged. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA 1/2 Panel provided on August 11, 2023, 
and billed with codes 81432 and 81433. 
 
You asked the Plan to pay for the Invitae BRCA 1/2 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 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.   
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 Invitae BRCA 1/2 Panel provided on August 11, 2023, and billed with codes 
81432 and 81433.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 1, 2023, to May 30, 
2023. 
 You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 1, 2023. The NOA was not received by the Plan until June 2, 2023. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for home health services provided from May 1, 
2023, to May 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on July 7, 2023. 
 
You asked the Plan to pay for the non-emergent services. You say that the hospital recommended transfer to 
the rehab facility. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the record indicates that you 
were ambulatory, able to sit in a chair, and were transported via stretcher. The record does not indicate that 
your clinical condition is such that other methods of transport, such as a stretcher van, are contraindicated or 
that the expertise, services, and lifesaving and life-sustaining equipment that only a fully equipped ambulance 
can provide was required. 
 
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 non-emergent services have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance services provided on July 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on May 19, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
that the documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on June 22, 2023. 
 
You asked the Plan to pay for the injections. You say that you are asking for the review of the submitted 
documents. 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 injections provided 
on June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 the laboratory services provided on July 27, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81479) provided on June 13, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the test was not listed as covered on the DEX registry as of the date of 
service. 
 
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 provided no documentation showing that this test was non-
covered at the time it was provided. The PrismRA test is currently listed as covered on the DEX registry. 
Therefore, we decided that the Plan has to pay for genetic testing (81479) provided on June 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87640, 87652, 87798, 87799, 
87900) provided on July 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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.   
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 lab services (87481, 87500, 87640, 87652, 87798, 87799, 87900) provided on 
July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service August 27, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that the records should be reviewed, and the 
claim reconsidered for payment. The Plan denied your request. The Plan says procedure codes 00790, 76937, 
36620, 36556 have been overturned. The Plan also says procedure code 99140 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service August 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 28, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on July 28, 2023.