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

 
We decided that the Plan does not have to pay for CPAP device and humidifier rental provided on February 21, 
2020. 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says if a PAP device is replaced following the five (5) year RUL, there must be an in-person 
evaluation by their treating practitioner that documents that the beneficiary continues to use and benefit from 
the PAP device. The Plan states there is no requirement for a new sleep test or trial period. 
 
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. There is no supporting documentation 
of face-to-face with the physician. Therefore, we decided that the Plan does not have to pay for CPAP device 
and humidifier rental provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says members 
must receive care from a network provider and in most cases, care received from an out-of-network provider 
will not be covered, except for emergency care or urgently needed service and needed medical care that 
Medicare requires our plan to cover and the providers in our network cannot provide this care, which requires 
authorization. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided by an oral surgeon on January 28, 
2020. 
 
You asked the Plan to pay for the extraction. You say that the tooth was extracted because it broke off at the 
gum line. You say that you paid in full and $245 should be returned. The Plan denied your request. The Plan 
says services performed by an oral surgeon 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 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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pay for the extraction provided by an oral surgeon on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 18, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the inpatient admission was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the member's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on February 7, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 and the referring provider are not network providers with the Plan. 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 drug test provided on February 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00790) provided on October 13, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service 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 00790 is anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified.  
 
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 anesthesia services. Our reviewer says that CPT code 
00790 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation 
submitted does not include sufficient information to verify this service. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (00790) provided on October 13, 2019.
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 the home ventilator. You say that you would like reconsideration because 
the member has been diagnosed with chronic hypercapnic respiratory failure and requires non-invasive 
ventilator. 
 The Plan denied your request. The Plan says this supply is not medically necessary. 
 
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 the home ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member does not have a covered diagnosis, is not using the Trilogy ventilator 
enough to provide any benefit and does not meet the minimum usage criteria of at least 4 hrs/day for 70% of 
days. 
 
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 (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the abdomen. 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because the 
enrollee has completed a colonoscopy and an ultrasound, with the ultrasound noting possible cirrhosis. The 
Plan denied your request. The Plan says the record shows no recent documentation of an unclear diagnostic 
ultrasound. 
 
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 
there is no medical necessity for the requested service. Our physician reviewer found the records showed no 
recent documentation of unclear or nondiagnostic ultrasound, nor was there any evidence of acute cholecystitis 
from the ultrasound records in 2019. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided December 20, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says hearing aids are only covered when ordered from the contracted provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered from the plan contracted provider.  
 
We looked at the file and the Plan's rules. The hearing aids were obtained from an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids (V5298) provided December 20, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 9, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 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 subsequent nursing facility care provided on June 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received from January 5, 2020 to 
January 18, 2020. 
 
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 services were obtained from a provider who is not under contract with the health plan and is 
not certified for Medicare. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that 
services must be provided by providers who are enrolled in the Medicare program. 
 
You are not eligible to bill Medicare. The Plan did not pre-approve the services. 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 home health services received from January 5, 2020 to January 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the two additional visits 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 the additional visits. Our reviewer says 
that records do not show that the two denied skilled therapy services are required to effectively provide 
treatment, care, and/or services in order to improve the member's  level of function, or to establish/perform a 
maintenance program to maintain the member's level of function and/or prevent deterioration. Our physician 
reviewer found the member has had prior physical therapy for this condition and her functional level does not 
require the ongoing expertise of a skilled therapist. She should be able to transition to a home exercise program 
with the already authorized therapy. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 25, 
2020. 
 
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 several attempts were made to obtain additional information to support the procedure codes for 
this date of service. 
 
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 the denied CPT codes are not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 laboratory services provided to the 
enrollee on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 2, 2020 and January 
14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on January 2, 2020 and January 
14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder test provided to the enrollee on March 4, 
2020. 
 
You asked the Plan to pay for the test. You say that this test is a non-invasive urine-based laboratory developed 
test that can rapidly detect potential urothelial cancer in patients. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee is noted to have a long urologic history including BPH and hematuria.  The enrollee has undergone 
cystoscopies and a TURP.  Cancer has not previously been identified.  The performed genetic testing is a 
screening/predictive tool.  It is not diagnostic and would not alter the need to monitor/treat this enrollee's 
ongoing symptoms.  The documentation does not support that the provided test was medically necessary or 
reasonable. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CXbladder test provided to the enrollee on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen. You say that you would like reconsideration because 
your current concentrator is too big to carry from room to room. The Plan denied your request. The Plan says 
you do not have a documented oxygen saturation of 89% or below. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen. Our reviewer says 
that the records provided do not document an oxygen saturation less than 89% while breathing room air, either 
at rest or with exercise. Our physician reviewer found home supplemental oxygen, including a portable oxygen 
concentrator, is considered not medically 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 the portable oxygen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on October 17, 2019. 
 
You asked the Plan to pay for the radiology services. You say that this should be covered. The Plan denied 
your request. The Plan says that this was denied as an exact duplicate claim and cannot be 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. This claim was denied stating this was a duplicate claim and that payment has 
already been made for these services on a different claim. However, the Plan did not provide us with evidence 
that payment was made for these services on a separate claim. Without this documentation, we cannot confirm 
the denial of payment in this case. Therefore, we decided that the Plan has to pay for the radiology services 
provided on October 17, 2019.  
 
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.