Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390) provided
to the enrollee on January 12, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that the durable medical equipment is
medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not
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 pay for the oxygen concentrator. Our physician
reviewer found coverage criteria for continued home oxygen supplementation are not met. The patient has not
had qualifying oximetry testing since 2008. Also, the clinical records do not indicate whether obstructive sleep
apnea has been ruled out as a possible cause of the nocturnal hypoxemia. The patient would need repeat
overnight oximetry on room air showing at least 5 minutes of saturation less than or equal to 88%, with OSA
excluded as a cause, or other qualifying oxygenation data.
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 oxygen concentrator have not been met. Therefore, we decided that the Plan
does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater
oxygen concentration at the prescribed flow rate (CPT Code E1390) provided to the enrollee on January 12,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory assist device, bi-level pressure capability, with
back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with
continuous positive airway pressure device) (E0471), tubing with integrated heating element for use with
positive airway pressure device (A4604), full face mask used with positive airway pressure device, each
(A7030) and face mask interface, replacement for full face mask, each (A7031) provided to the enrollee on
June 28, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure
Coding System (HCPCS) codes E0471-RR-KX-KH (1 Unit), A4604-NU-KX (1 Unit), A7030-NU-KX (1 Unit)
and A7031-NU-KX (3 Units) remain not supported. The documentation submitted did not include an itemized
shipping/billing invoice from the billing provider to indicate the specific supplies. Therefore, the billed supply
code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional
information. Therefore, we decided that the Plan does not have to pay for respiratory assist device, bi-level
pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask
(intermittent assist device with continuous positive airway pressure device) (E0471), tubing with integrated
heating element for use with positive airway pressure device (A4604), full face mask used with positive airway
pressure device, each (A7030) and face mask interface, replacement for full face mask, each (A7031) provided
to the enrollee on June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) and red blood cells (P9022) provided on December 30, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger and red blood cells. You say that this should be covered. The Plan denied your request. The Plan says payment for these services is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary
while an inpatient. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Because of this, the red blood cells also cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) and red blood cells (P9022) provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy; initial assessment and
intervention, individual, face-to-face with the patient, each 15 minutes (97802) provided on February 3, 2020
with an out-of-network, non-certified Medicare provider.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says your plan does not cover this expense as well as the
provider has opted out of Medicare.
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 plan searched all systems and there are no physician orders, referrals or medical criteria for the plan to
review. In addition, the plan reviewed the provider's network status and this provider opted out of Medicare on
March 16, 2016 per Medicare, CMS.gov., and it continues until March 16, 2020 which was after the date of
service, February 3, 2020. Therefore, we decided that the Plan does not have to pay for medical nutrition
therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97802)
provided on February 3, 2020 with an out-of-network, non-certified Medicare provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on February 20, 2020.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians
custom profile. The Plan denied your request. The Plan says the documentation did not include a physician
order or medical records stating exactly what tests are to be performed.
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 G0483 is definitive drug tests of 22 or more drug classes.
We find that CPT code G0483 is not supported in the medical record. There is no evidence that shows the test
was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records
provided do not document concerns based on clinical review and judgement. Based on this information, we
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have
to pay for the definitive drug testing provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on December 23, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you cannot get approval as soon as possible. The
Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and
authorization for certain services.
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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the imaging services provided on December 23, 2019 by an out of network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection and application of autologous blood
concentrate product (D7921) and bone replacement graft (D7953) provided on February 11, 2020.
You asked the Plan to pay for the collection and application of autologous blood concentrate product and bone
replacement graft. You say that you are on a limited income. The Plan denied your request. The Plan says these
services are not covered under the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
collection and application of autologous blood concentrate product (D7921) and bone replacement graft
(D7953) provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal manipulation (98943) provided on January 24,
2020 through February 6, 2020.
You asked the Plan to pay for the extraspinal manipulation. You say that you would like reconsideration
because you do not know why you are being asked to pay more than your copayment. The Plan denied your
request. The Plan says extraspinal manipulation is not covered.
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 Plan offers an additional chiropractic benefit;
therefore, the Plan's rules apply. The Plan rules say that extraspinal manipulation is not covered.
The records show that the service at issue is extraspinal manipulation. Therefore, we decided that the Plan does
not have to pay for extraspinal manipulation (98943) provided on January 24, 2020 through February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on
February 18, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the
documentation submitted did not include a valid physician order/lab requisition or medical records signed by
the ordering physician stating exactly what tests were to be performed. Based on this information, we decided
that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing coded G0483 and 80307 provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided on December 10, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because the
anesthesia services were medically necessary based on the member's medical condition. The Plan denied your
request. The Plan says additional payment for anesthesia services due to the member's age is not a covered
benefit.
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 the
anesthesia services has a bundled relationship with code 00520 and cannot be paid as billed. This code cannot
be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on
December 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services provided to the enrollee on
August 28, 2018.
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 Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year
form the date when the services were rendered.
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 the services was not filed until March 25, 2020. 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 emergency department services provided to the enrollee on August 28, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the ankle foot orthoses
provided on December 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650) and the ankle foot orthoses (L1906). You say
that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted
did not include an itemized shipping/billing invoice or proof of delivery indicating the specific supplies
dispensed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. There is no itemized delivery ticket or itemized shipping invoice in the file. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis and the ankle foot orthoses provided on
December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for re-treatment of previous root canal therapy- tooth 18
(D3348) provided January 29, 2020.
You asked the Plan to pay for the dental services. You say that you went to have a root canal done and the
dentist informed you that the tooth had a previous root canal and this would be a re-treat. It never occurred to
you that a re-treat would not be covered. The Plan denied your request. The Plan says this service is not
covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for retreatment
of previous root canal therapy- tooth 18 (D3348) provided January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2020.
You asked the Plan to pay for the laboratory services. 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. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder test provided on January 17, 2020.
You asked the Plan to pay for the services provided. You say that the test was ordered to aid in the diagnosis of new or recurrent bladder cancer. The Plan denied your request. The Plan says genetic screening testing is not a Medicare benefit for the diagnoses listed on the claim.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the services provided, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the Cxbladder test provided on January 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid.
You asked the Plan to pre-approve Synthroid. You say that the enrollee has been stable on Synthroid since starting his therapy. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Synthroid.
Benefits for Synthroid 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve, first two
vertebral bodies (C9752), destruction of intraosseous basivertebral nerve, each additional vertebral body
(C9752), and a spine surgery procedure (22899).
You asked the Plan to pre-approve destruction of intraosseous basivertebral nerve, first two vertebral bodies,
destruction of intraosseous basivertebral nerve, each additional vertebral body, and a spine surgery procedure.
You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not
been established. Therefore, coverage criteria has not been met.
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 destruction of intraosseous
basivertebral nerve, first two vertebral bodies, destruction of intraosseous basivertebral nerve, each additional
vertebral body, and a spine surgery procedure. Our reviewer says that the requested services are not considered
medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/
investigational procedure and there is no long term follow-up of procedure. Therefore, the request is not
medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of destruction of intraosseous basivertebral nerve, first two vertebral bodies,
destruction of intraosseous basivertebral nerve, each additional vertebral body, and a spine surgery procedure
have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of
intraosseous basivertebral nerve, first two vertebral bodies (C9752), destruction of intraosseous basivertebral
nerve, each additional vertebral body (C9752), and a spine surgery procedure (22899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (MNT) (97802) provided on January 9, 2020.
You asked the Plan to pay for medical nutrition therapy. You say that this should be paid in full. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that a referral for medical nutrition therapy (MNT) may only be made by the treating physician when the beneficiary has been diagnosed with diabetes or renal disease. We looked at the file and Medicare rules. The medical records submitted do not show that the beneficiary has been diagnosed with diabetes or renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (MNT) (97802) provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on November 20, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because this claim was erroneously denied as inclusive to another procedure. The Plan denied your request. The Plan says that payment is not allowed because this claim contains non-anesthesia services submitted by an anesthesiologist.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was provided by a provider different than that of the anesthesia procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on November 20, 2019.