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

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says in the absence of 
clinical information, medical necessity and coverage cannot be determined. With the information we have, we 
cannot determine how the member came to the servicing provider, or whether the services are medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit have been met. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee on May 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that the member must receive care from a network provider, or it will 
not be covered except for urgent/emergency care. 
 
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 had network providers 
available who could have provided 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 skilled nursing facility (SNF) services 
provided to the enrollee on May 30, 2022, 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/bath chair. 
 
You asked the Plan to pre-approve a shower/bath chair. You say that a shower/bath chair is medically 
necessary. The Plan denied your request. The Plan says this type of equipment is not covered by Medicare. 
 
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/bath chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on August 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that the eyelid was obstructing your vision. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient records, such as visual field testing 
and margin reflex distance, to determine if the coverage criteria have been met. Therefore, we decided that the 
Plan does not have to pay for the surgery services provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided the Plan does not have to pay for the Inogen portable oxygen concentrator purchased April 7, 
2022. 
 
You asked the Plan to pay for this equipment. You say that you believe the Plan should pay for this equipment. 
The Plan denied your request. The Plan says all oxygen equipment must be rented for Medicare coverage. 
Purchase is not covered. 
 
The Plan must follow Medicare rules. The rules say oxygen equipment is a rental item and will not be covered 
if purchases. The Plan contract clearly stated oxygen equipment must be rented. Therefore, we decided that the 
Plan does not have to pay for the Inogen portable oxygen concentrator purchased on April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary to help the 
patient gain strength. The Plan denied your request. The Plan says IRF admission is not medically necessary as 
the patient's condition can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient does not require the intensity of services provided at an IRF.  Specifically, the patient is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services 
with regular physician evaluation.  The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided to the enrollee on April 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
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 had network providers available who could have provided 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 provided to the enrollee on April 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader. 
 
You asked the Plan to pre-approve continuous glucose monitor (CGM). You say that the enrollee needs this. 
The Plan denied your request. The Plan says the requested CGM is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, nor requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous 
glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on May 18, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00811 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified. 
 
We find that CPT code 00811 is not supported in the medical record. Specifically, the documentation submitted 
does not support that the enrollee underwent two separate anesthesia/operative sessions on this date of service 
at different times. The documented anesthesia is for a duration of 17 minutes for a flexible sigmoidoscopy. The 
documentation does not support an additional anesthesia service. 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 the anesthesia services provided on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on January 
28, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you don't believe you 
should pay another copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital facility 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 outpatient surgery provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on June 22, 2022, by an 
provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you were not aware that prior authorization was 
required. The Plan denied your request. The Plan says the out-of-network services were 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 had network providers 
available who could have provided 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 outpatient surgery provided on June 22, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided on March 28, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the orthotics are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics provided on March 
28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454 provided on June 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code has not 
met the diagnosis code criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 64454 is injection(s), anesthetic agent(s) and/or steroid; 
genicular nerve branches, including imaging guidance, when performed. We find that CPT code 64454 was 
billed with diagnosis codes G89.29 and M17.0. The billed diagnosis codes are not among those covered for the 
provided service.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 64454 provided on June 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 99214. The Plan denied your request. The Plan says payment for 
code 99214 is bundled into payment for code 99223. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 billed for date of service May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the human leukocyte antigen (HLA) class I and II typing 
high resolution (81378) provided on January 5, 2022. 
 
You asked the Plan to pay for the HLA typing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81378 is not covered. 
 
We looked at the file and Medicare rules. The requested service is not covered under Medicare. Based on this 
information, we decided that Medicare rules for coverage of the HLA typing have not been met. Therefore, we 
decided that the Plan does not have to pay for the human leukocyte antigen (HLA) class I and II typing high 
resolution (81378) provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery backup for a continuous passive airway pressure 
(CPAP) machine. 
 
You asked the Plan to pre-approve battery backup. You say that battery backup is medically necessary. The 
Plan denied your request. The Plan says battery backup is precautionary and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not pay for precautionary equipment. Battery backup for 
a CPAP in case there is no power is precautionary. Therefore, we decided that the Plan does not have to pre-
approve battery backup for a continuous passive airway pressure (CPAP) machine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS) using a Sprint 
device. 
 
You asked the Plan to pre-approve Sprint device. You say that the enrollee has tried all conventional treatment 
options with no sustained pain relief. The Plan denied your request. The Plan says the requested SPR Sprint 
device is not covered. 
 
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 Sprint device. Our reviewer says that 
the requested Sprint device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient clinical evidence to support the use of a Sprint peripheral nerve stimulation 
(PNS) for low back pain or failed back surgery syndrome. The reviewer found that the requested procedure is 
considered experimental and investigational for this indication.  Therefore, the reviewer found that the 
requested Sprint device is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sprint device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve stimulation (PNS) using a Sprint device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional pulmonary rehabilitation visits (94625). 
 
You asked the Plan to pre-approve pulmonary rehabilitation. You say that these classes are necessary, and you 
feel your condition has gotten worse since you have not been able to go to these therapy sessions. The Plan 
denied your request. The Plan says you have exhausted the entire 72 available lifetime pulmonary therapy 
visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. The services must be provided in a doctors office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
medically necessary.  
 
We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of pulmonary rehabilitation have not been met. Specifically, the record shows that you have met the maximum 
limit of 72 visits (36 with an additional 36 if medically necessary) per lifetime. Therefore, we decided that the 
Plan does not have to pre-approve additional pulmonary rehabilitation visits (94625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36223 and 37215 billed for date of service 
March 8, 2022. 
 
You asked the Plan to pay for procedure codes 36223 and 37215. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 36223 and 37215 have not been met. Specifically, the documentation submitted 
does not include a valid signature from the persons responsible for the care of the beneficiary. Therefore, we decided that the Plan does not have to pay for procedure codes 36223 and 37215 billed for date of service 
March 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided to the enrollee on 
May 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that services from non-participating providers are not 
covered unless preauthorized. 
 
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 had network providers 
available who could have provided 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 physical therapy services provided to the 
enrollee on May 18, 2022, by an out-of-network (OON) provider.