Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided on January 15, 2019. 
 
You asked the Plan to pay for hospital care. You say that this claim was timely and has been resubmitted 
multiple times. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 hospital care was not received by the Plan until September 1, 2020. There is 
insufficient information to support accurate and timely prior filing. 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 hospital care (99232) provided on January 15, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that portable oxygen is covered when specific criteria 
are met. 
 
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 medically necessary. Our physician reviewer found the enrollee has diagnoses of chronic 
obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). He requires oxygen with exertion 
and the physician notes that he is unable to use portable compressed oxygen tanks due to frailty. The requested 
portable oxygen concentrator is therefore reasonable and medically necessary to maintain mobility within the 
home. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a portable oxygen concentrator.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatry services provided on August 21, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the psychiatry services. You say that you need to see this provider because you 
have been a patient for a long time.  You say that you want the Plan to cover these expenses. The Plan denied 
your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could 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 psychiatry services provided on August 21, 2020 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental pneumatic compressor device and a segmental 
pneumatic appliance provided on July 8, 2020. 
 
 
 
You asked the Plan to pay for the segmental pneumatic compressor device and the segmental pneumatic 
appliance. You say that the information provided supports the items in dispute. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices and appliances are 
covered for certain medical indications.  
 
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 segmental pneumatic compressor device 
and the segmental pneumatic appliance. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the documentation states the enrollee has a diagnosis of coronary artery disease, 
chronic obstructive pulmonary disease, hypertension, and liver cirrhosis.  The documentation notes the enrollee 
has lower extremity edema and take oral diuretic medications.  The documentation does not indicate the 
enrollee has venous stasis pressure ulcers. Additionally, the documentation does not support a trial of 
conservative 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 segmental pneumatic compressor device and the segmental pneumatic 
appliance have not been met. Therefore, we decided that the Plan does not have to pay for a segmental 
pneumatic compressor device and a segmental pneumatic appliance provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95907) provided on December 16, 
2019. 
 
You asked the Plan to pay for nerve conduction studies. You say that this code is supported. The Plan denied 
your request. The Plan says this code is not documented. 
 
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 95907 is nerve conduction studies; 1-2 studies. 
 
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 nerve conduction studies. Our reviewer says 
that this code is not supported. Our physician reviewer found the technical report did not include 
documentation of nerve conduction studies. It cannot be verified that this service was performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve conduction studies have not been met. Therefore, we decided that the 
Plan does not have to pay for nerve conduction studies (95907) provided on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Levetiracetam 250 mg tablet. 
 
You asked the Plan to pre-approve Levetiracetam. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your 
medical benefit. 
 
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 the Levetiracetam 250 mg 
tablet.  
 
Benefits for Levetiracetam 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and these tests could be performed by an in-network provider. 
 
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 medical services provided on February 24, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second confirmatory facet joint injection, also known 
as a medial branch block (MBB). 
 
You asked the Plan to pre-approve the second MBB. You say that this is necessary to confirm diagnosis of 
facet joint pain and allow to proceed to radiofrequency ablation. The Plan denied your request. The Plan says 
the enrollee's pain is not of the type for which this can be covered. 
 
 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for certain types of 
pain. Confirmatory MBBs may be covered when the initial treatment provides a positive response.  
 
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 second MBB. Our reviewer says 
that the documentation does not support the requested MBB. Our physician reviewer found the enrollee reports 
bilateral back pain radiating to both feet with severe stenosis on medical imaging. There was also insufficient 
documentation of pain reduction and functional benefit with prior blocks. While pain relief of 75 percent and 
80 percent was noted on the left side only, there was no functional benefit documented. The review has 
determined that the criteria for the requested facet joint injection have not been met. 
 
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 second MBB have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a second confirmatory facet joint injection, also known as a medial branch block 
(MBB).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88321) provided. 
 
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for pathology services (88321) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on July 29, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the scan was needed for a follow up. 
You say that you know it is covered but it wasn't paid. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for advanced imaging services at an in-network outpatient hospital.  
 
The allowed amount for the CT scan is $110.94. You have only been asked to pay $110.94 because it is less 
than the standard $180 copayment for the CT scan. The CT scan 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 copayment for 
the CT scan provided on July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered to be experimental. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the procedure 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 the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 30, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges 
because this was your annual wellness exam. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 primary care physician visits.  
 
The medical records show that you received services beyond an annual wellness exam on July 30, 2020. 
Therefore, you are responsible to pay the $20 copayment.  
 
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor's office visits 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 an office visit provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on January 9, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for OON services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 outpatient services provided on January 9, 
2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physician re-certification for Medicare-covered home health 
services (G0179) provided on October 16, 2019. 
 
You asked the Plan to pay for Physician re-certification for Medicare-covered home health services. You say 
that the service was medically necessary. The Plan denied your request. The Plan says there are no records 
showing that you were receiving home health services immediately prior to the request for this visit 
 
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 G0179 is Physician re-certification for Medicare-covered 
home health services. 
 
We find that CPT code G0179 is not supported in the medical record. Specifically, the records submitted 
included three pages which showed interpretation of imaging studies. The records did not include any mention 
of the need for home health care or that this was the reason for the services. Based on this information, we 
decided that Medicare rules for coverage of Physician re-certification for Medicare-covered home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for Physician re-
certification for Medicare-covered home health services (G0179) provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says a semi-electric bed can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient care provided from February 7, 
2020 to February 13, 2020. 
 
You asked the Plan to waive the copayment for inpatient care. You say that this should be fully covered. The 
Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 
copayment for each inpatient admission.  
 
You have been asked to pay a $500 copayment for inpatient care. 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 inpatient care provided from February 7, 2020 to February 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home physical therapy. 
You asked the Plan to pre-approve the home physical therapy. You say that you just had eye surgery and you 
are having trouble seeing and with limited transportation rides, you cannot afford to go to outpatient physical 
therapy and need in home physical therapy. The Plan denied your request. The Plan says there is no 
information showing that the you are weaker than usual and would need the help of a skilled physical therapist 
after eye surgery. 
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 the home physical therapy. Our 
reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not 
generally accepted as specific and effective therapy for your condition. You have chronic spastic cerebral palsy 
and a recent eye surgery. The documentation does not reveal evidence of a recent change in function therefore, 
it does not appear that you require the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist.  
The documentation does not support that 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. 
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 physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home physical therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on 
September 10, 2020. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection (J0178). You say that the doctor said 
you would not have a payment. The Plan denied your request. The Plan says you were charged the coinsurance 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the aflibercept injection. The aflibercept injection falls 
within the Medicare Part B prescription drugs 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 the aflibercept injection provided on September 10, 2020.