Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 25, 2022. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed as the 
date in question is a payable. The Plan denied your request. The Plan says the Plan does not have a contractual 
obligation for services rendered on the date of death of the enrollee. 
 
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 medical services provided on 
January 25, 2022, have been met. Specifically, no documentation was provided to corroborate the services received on the date in question. Without documentation detailing the services rendered, payment cannot be 
made. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 
25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for office visit services provided to the enrollee on April 9, 2021. 
 
You asked the Plan to pay for the services. You say that the place of service is appropriate and no changes can 
be made. The Plan denied your request. The Plan says that an inappropriate place of service was reported. 
 
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. Medicare rules say that providers must report services correctly. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in a meaningful way. The plan has not 
stated what was wrong with the place of service in this case. The plan has not stated what the correct place of 
service would be, so the claim could be corrected on the provider's end. The claim was billed with modifier 95, 
which indicates that this was a telemedicine visit. The case file indicates that the delivery of the services was 
through interactive audio, and that the patient's location was home. It appears that the modifier was used 
correctly in this case. Therefore, we decided that the Plan has to pay for office visit services provided to the 
enrollee on April 9, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on December 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on December 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing services provided on May 21, 2021. 
 
You asked the Plan to pay for the CxBladder testing services. You say that you would like this testing 
reprocessed for payment based on medical necessity. The Plan denied your request. The Plan says the 
CxBladder testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the CxBladder testing services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is an 88-year-old male with a distant history of superficial bladder cancer 
treated with trans urethral resection of bladder tumor and intravesical Bacillus Calmette-Guerin in 2014. 
CxBladder is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and 
low-grade tumors. The testing was not medically necessary, and no payment will be made for these services. 
 
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 CxBladder testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the CxBladder testing services provided on May 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided to the enrollee on February 3, 2022. 
 
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 provider did not bill as required by Medicare coding regulations. 
 
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 93880 is a column II code to column I code 76536. 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 a duplex scan provided to the enrollee on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, shoulder provided on  
January 20, 2022. 
 
You asked the Plan to pay for a radiologic examination, shoulder. The Plan denied your request. The Plan says 
the primary insurance carrier did not provide an explanation of benefits (EOB). In addition, the providers 
office is unable to provide the EOB. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not been able 
to obtain the EOB. As the secondary insurer, the Plan cannot be held responsible for a radiologic examination, 
shoulder until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for a radiologic examination, shoulder provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic recording for more than 48 
hours up to 7 days by continuous rhythm recording and storage; scanning analysis with report provided to the 
enrollee on January 7, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there were no clinical records submitted that discussed the previous history and work-up to support the 
rationale for this ambulatory electrocardiogram (ECG) monitor. As a result, authorization and reimbursement for an ambulatory ECG monitor would not be considered medically appropriate and necessary in this patients 
clinical management. 
 
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 external electrocardiographic recording for more than 48 hours up to 7 days by continuous 
rhythm recording and storage; scanning analysis with report provided to the enrollee on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator provided to the enrollee on 
January 4, 2022. 
 
You asked the Plan to pay for the concentrator. You say that this was medically necessary. The Plan denied 
your request. The Plan says the item at issue in this appeal performs the same function as equipment currently 
used for oxygen needs. 
 
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 pay for the concentrator. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that no medical 
records have been provided in this case documenting hypoxemia. A statement from the enrollee indicates the 
oxygen concentrator purchased on 01/04/2022 was for use outside the home. Under Medicare definitions 
covered durable medical equipment is for use within the home; equipment specifically for use outside the home 
is not covered.  
 
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 pay for a portable oxygen concentrator provided to the enrollee on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 20, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on July 2, 2021. 
 
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 that this is a correction of a previous paid claim, and this correction resulted in an overpayment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has made very little effort to substantiate their denial. The denial 
reason is unclear and vague, and there is no information what reason the claim might have been overpaid. 
Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on July 2, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure 
provided on September 2, 2021. 
 
You asked the Plan to pay for the genicular nerve radiofrequency ablation procedure. You say that this 
procedure was medically necessary and should be paid. The Plan denied your request. The Plan says the 
requested procedure is considered experimental/investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genicular nerve radiofrequency ablation 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational 
and is the subject of ongoing clinical trials. Therefore, the request is deemed 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 the genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation 
procedure provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on October 31, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the billed critical care evaluation 
and management code cannot be verified. 
 
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, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
provide evidence that between 30-74 minutes were spent providing critical care services. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on 
October 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal care services provided from November 1, 2021, 
through November 28, 2021. 
 
You asked the Plan to pay for personal care services. The Plan denied your request. The Plan says under 
Medicare and the Plan guidelines, your request is not a covered benefit because these services represent 
custodial care. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for personal care services provided from November 1, 2021, 
through November 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on November 20, 2021 to December 19, 2021. 
 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 skilled services could have been provided on an intermittent outpatient basis, in a long-term care 
facility, or at home with home health care services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found you no 
longer qualified for skilled nursing facility (SNF) coverage. You did not have documented skilled nursing 
needs. You did not have documented skilled therapy needs. Daily skilled services were not required to establish 
a maintenance program or to prevent deterioration of your condition. Your care needs were custodial and, as a 
practical matter, could be provided 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee on November 20, 2021 to 
December 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the lower extremity 
rendered on February 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 73700 has an OPPS status indicator of Q3 and 
is paid as a packaged service. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan of the lower extremity rendered on February 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291 and 99292) provided to the 
enrollee on November 4, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says these 
codes are disallowed within the global period. 
 
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 CPT code 99291 and 99292 is not supported in the medical record. Specifically, these codes were 
billed within the global period of the main procedure - CPT 36556. 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 (99291 and 99292) provided to the enrollee on November 4, 2021.