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

We decided that the Plan does not have to pre-approve stationary compressed gaseous oxygen system, rental; 
includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (CPT 
Code E0424). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the clinical documentation received states that H Tank (stationary) oxygen requested by 
physician is for the purpose of prevention or caution. The Plan states the Medicare Policy that does not cover 
additional oxygen or because it is not considered a medical necessity. 
 
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 services. Our physician reviewer 
found the coverage criteria for a back-up compressed air tank are not met. You have systemic lupus with 
pulmonary involvement. Overnight oximetry shows mild oxygen desaturation, meeting requirements for 
supplemental oxygen. Presumably you have a stationary oxygen concentrator, although this is not clear from 
the records. Medicare does not cover duplicate oxygen systems. The H-tank is not mentioned or justified in the 
medical record. The H-tank is not medically necessary, and the denial is upheld. 
 
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 pre-approve stationary compressed gaseous oxygen system, rental; includes container, contents, 
regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (CPT Code E0424).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a diagnostic esophagogastroduodenoscopy 
(43235) performed on June 10, 2020, and a transthoracic echocardiography (93306) performed on June 22, 
2020. 
 
You asked the Plan to waive the copayments for a diagnostic esophagogastroduodenoscopy and a transthoracic 
echocardiography. You say that you wish to appeal your cost-sharing responsibility. The Plan denied your 
request. The Plan says the correct copayments were 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 $245 
copayment for Medicare-covered surgery and a $160 copayment for each Medicare-covered radiological 
diagnostic service, not including X-rays.  
 
You have been asked to pay a $245 copayment for a diagnostic esophagogastroduodenoscopy and a $160 
copayment for a transthoracic echocardiography. A diagnostic esophagogastroduodenoscopy falls within the 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" benefit category. A transthoracic echocardiography falls within the "Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies" 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 copayments 
for a diagnostic esophagogastroduodenoscopy (43235) performed on June 10, 2020, and a transthoracic 
echocardiography (93306) performed on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Desvenlafaxine Succnt ER 100MG. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 Desvenlafaxine Succnt ER 
100MG.  
 
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided 
from November 16, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health 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 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 pre-approve inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this enrollee does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 
16, 2020, forward as this patient was not shown to be a danger to themselves or others. The enrollee was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care provided from November 16, 
2020, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMs HF System.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are notcovered. 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 the services are not medically necessary. Our physician reviewer found the enrollee has coronary artery disease status post coronary artery bypass graft, cardiorenal syndrome, and NYHA class III congestive heart failure with reduced left ventricular ejection fraction (less than 20 percent) requiring hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. The efficacy of the CardioMEMs device is uncertain and the services are considered experimental in nature. The services are therefore 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-approvea CardioMEMs HF System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) provided. 
 
You asked the Plan to pay for the resin-based composite. You say that you feel that a correction was necessary. 
The Plan denied your request. The Plan says resin-based composite for posterior teeth is not a covered benefit. 
The Plan also says that the cost of an amalgam filling has been 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 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 resin-
based composite (D2392) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 facility. The review has determined that the 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0382) provided on May 6, 
2019. 
 
You asked the Plan to pay for the routine disposable supplies. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the routine disposable supplies 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2006, items and services 
which include but are not limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and 
night differential are no longer paid separately for ambulance services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine disposable supplies have not been met. Specifically, these supplies are not separately 
payable from the ambulance transport. Therefore, we decided that the Plan does not have to pay for the routine 
disposable supplies (A0382) provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on November 5, 2019.You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $20 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $20 copayment for lab work. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 facility. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where the enrollee 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar Vertiflex Interspinous and/or interlaminar 
device (CPT Code 22869). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lumbar Vertiflex Interspinous and/or interlaminar device (CPT Code 22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 17, 
2020, and billed under code 80307.  
 
You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. The 
Plan says while a portion of this claim was paid, the documentation submitted did not include a valid physician 
order/lab requisition or medical records for code 80307. It is noted multiple attempts were made to obtain 
additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide the required documentation to support 
the services billed. In this case, invalid documentation was submitted to support the payment of code 80307. 
 
 
Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on 
February 17, 2020, and billed under code 80307.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for the hyperbaric oxygen under pressure full 
body chamber provided on May 11, 2020, to May 29, 2020. 
 
You asked the Plan waive the copayment for the hyperbaric oxygen under pressure. You say that you were not 
satisfied with the bill you received and was expecting to pay a smaller copay. The Plan denied your request. 
The Plan says the copayment applied correctly in this case. 
 
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 $395 
copayment for hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $395 copayment for the hyperbaric oxygen under pressure. This service falls 
within the 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 waive the copayment for the hyperbaric oxygen under pressure full body chamber provided on 
May 11, 2020, to May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breath test provided on March 30, 2020. 
 
You asked the Plan to pay for the breath test. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
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 breath test, 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 
breath test provided on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
provided on May 14, 2018. 
 
You asked the Plan to pay for the endosteal implant. You say that you would like to be reimbursed for this 
service. The Plan denied your request. The Plan says this service is not a Medicare or Plan covered benefit. The 
Plan also says that there is no supplemental plan benefit for this service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant 
body: endosteal implant provided on May 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with vaccine for influenza (99214, 90686, 
G0008) provided on October 14, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with vaccine for influenza. 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 vaccine for influenza (99214, 
90686, G0008) provided on October 14, 2019, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your alone and this is medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the medical services provided on May 25, 2020. 
 
You asked the Plan to pay for the services provided. You say that the physician's qualifications allow the 
billing for the services provided. The Plan denied your request. The Plan says that audiological diagnostic tests 
are not covered for services incident to a physician's 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 records show that cardiology evaluation and management services were provided for a diagnosis of 
unspecified atherosclerosis. There is no indication that audiology services were billed or performed. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the medical services provided on May 
25, 2020.  
 
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.