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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plan does not cover duplicative or redundant DME. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the medical 
records provided do not include an exercise oximetry test, and do not document need for home oxygen. You 
reportedly already have a portable oxygen system at home. There is no documentation that you maintain 
oxygen saturations during exercise using a conserving device, which is required for a portable oxygen 
concentrator. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you lost your denture. The 
Plan denied your request. The Plan says you have exhausted your denture benefit. 
 
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, dentures are limited to one per arch 
every 5 years. The record shows that you received a complete maxillary denture on February 16, 2016, and 
your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastrointestinal panel testing provided. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no 
documentation of immunodeficiency. 
 
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 testing services at issue are not supported in the medical record. Specifically, there are 
insufficient medical records to show that the testing results will be used to determine a specific diagnosis or 
treatment strategy. The testing services are not covered for screening purposes. 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 gastrointestinal panel testing provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on July 15, 2020. 
 
You asked the Plan to pay for the dental service. You say that you went in for a routine cleaning. You say that 
the dentist had to do a little more for your gums. You say that you do not expect the whole thing to be covered. 
You also say that you believe that the cleaning should be covered at least. The Plan denied your request. The 
Plan says scaling in presence of generalized moderate or severe gingival inflammation is not listed as a covered 
service. The Plan also says that any services not listed are not covered. 
 
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 scaling in presence of generalized 
moderate or severe gingival inflammation is not among those covered under this benefit. The Evidence of 
Coverage clearly states that any services no listed are not covered. Additionally, the record shows that the Plan 
paid for the oral exam and x-rays that you received on this date of service. Therefore, we decided that the Plan 
does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation 
(D4346) provided on July 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular stress test provided by an out-of-network 
provider on February 3, 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 plan requires you to see in-network providers. 
 
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 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 a cardiovascular stress test provided by an out-of-
network provider on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast reconstruction (19366) provided. 
 
You asked the Plan to pay for the breast reconstruction. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the CPT code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 19366 is Breast reconstruction, with other technique. 
 
We find that CPT code 19366 is not supported in the medical record. Specifically, the medical records 
submitted do not include sufficient documentation to validate the appropriateness of billing CPT 19366-50 to 
the health plan to represent the services performed, therefore this service cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the breast reconstruction have not been met. 
Therefore, we decided that the Plan does not have to pay for a breast reconstruction (19366) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheter based closure of congenital 
interatrial defect with implant, accessed through the skin provided on June 15, 2020 by an out-of-network 
provider. 
 
You asked the Plan to waive the coinsurance for catheter based closure of congenital interatrial defect with 
implant, accessed through the skin. You say that you were referred to the provider by another provider and 
believed it would be fully covered. The Plan denied your request. The Plan says the cost share is correct. 
 
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 20% 
coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay 20% coinsurance for catheter based closure of congenital interatrial defect with 
implant, accessed through the skin. This service falls within the Outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for catheter based closure of congenital interatrial defect with implant, accessed 
through the skin provided on June 15, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with X-ray of knee (73565, 20610, 99202, 
73560) provided on February 12, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with X-ray of knee. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 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 office visit with X-ray of knee (73565, 20610, 
99202, 73560) provided on February 12, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the 
enrollee from December 18, 2019, to April 22, 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 this code is not recognized for non-participating providers. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. 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 home infusion therapy 
(HCPCS S9328) provided to the enrollee from December 18, 2019, to April 22, 2020.
Appeal type: SNF
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care at the long term care hospital exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital and when considered medically stable 
by the treating team may be an appropriate candidate for care at a less intense level such as a skilled nursing 
facility (SNF). The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee 
on May 7, 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 Current Procedural Terminology (CPT) code 99291 (1 Units) remains not supported. 
 
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 99291 is "critical care visit, 30-74 minutes 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review has determined that the records did not support the coding of 99291. The records did not support a care 
visit of 30-74 minutes was provided on the date in question. The documentation does not include the time spent 
providing this service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (CPT 99291) provided to the enrollee on May 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 26, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
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 August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you need the dentures for proper chewing to 
avoid choking. You also say that your bottom dentures were lost when your purse was taken. The Plan denied 
your request. The Plan says denture are covered once every 5 plan years. The Plan also says that the frequency 
limit has been reached. 
 
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 and the partial denture is a covered 
service, the frequency limit of 1 denture every 5 plan years has been reached. The record shows that the Plan 
paid for a lower partial denture that you received on March 18, 2019. Therefore, we decided that the Plan does 
not have to pre-approve a lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that you believe that this should be 
covered. The Plan denied your request. The Plan says criteria for this device are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs may be covered for enrollees 
who are insulin-treated and require four or more glucose tests per day as well as three or more insulin 
injections. 
 
In this case, no documentation was submitted by the treating physician to demonstrate that the criteria for the 
CGM have been met, despite requests from the plan. Therefore, we decided that the Plan does not have to pre-
approve the Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not payable. 
 
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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora fluoroscopic guided injection (62323) provided March 31, 2020.You asked the Plan to waive the copayment forthe injection. You say that only a $45 copayment should be applied.The Plan denied your request. The Plan says the correct copayment was applied.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 $400 copayment for Outpatient Hospitalservices. You have been asked to pay a $400 copayment for the injection. The fluoroscopic guided injection falls within the Outpatient Hospital services 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 fora fluoroscopic guided injection (62323) provided March 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve these services. You say that the Plan does not have an aquatic therapy 
program. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the submitted records show that you have no pain complaints and the 
x-rays show progressive healing. The records do not support that you require the unique skills of a professional 
therapist to safely and effectively provide treatment, or be under supervision from a physical therapist. The 
requested therapy is not part of a maintenance program. You do not require the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. The requested therapy is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy.