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

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 an oxygen concentrator Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that coverage criteria for home oxygen therapy have been met in this 
case. Provided records document oxygen saturations of 93% and 96% on 2 liters nasal canula oxygen. Provided 
records do not document an arterial P O2 of 59 mm Hg or lower or a blood oxygen saturation of 89% or less as 
required by the Medicare National Coverage Determinations Manual, Section 240.2. Provided records are 
inadequate to fully certify that supplemental oxygen meets Medicare criteria for medically necessary and 
reasonable in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and intraoral - complete series of radiographic images tooth #'s 1 and 32 (D0210) provided on March 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that n?A The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service December 15, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and intraoral - complete series of radiographic images tooth #'s 1 and 32 (D0210) 
provided on March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 17, 2021, to March 20, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code R16.1 (Splenomegaly, not elsewhere classified) 
with DRG 801. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 801. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the enrollee was not symptomatic from the enlarged splee. The review has determined that the 
medical records did not support the billing of of principal diagnosis code R16.1 (Splenomegaly, not elsewhere 
classified) with DRG 801.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from March 17, 2021, to March 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15822 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 15822. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 15822 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 15822 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 15822 billed for date of service March 30, 2022.
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 from May 9, 2022, to June 7, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the limited documentation provided, the enrollee no longer qualified for 
SNF coverage after 5/8/22. There were no documented skilled nursing or skilled therapy needs. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs could, as a practical matter, 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 SNF care 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 from May 9, 2022, to June 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99316 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for code 99316. You say that this service was billed correctly. The Plan denied your 
request. The Plan says you billed an incorrect Place of Service (POS) code on the claim. 
 
The Plan must follow Medicare rules. The rules state that providers must bill with an appropriate Place of 
Service (POS) code that reflects where the service occurred. POS code 31 indicates that the service was 
provided in a skilled nursing facility setting. POS code 21 indicates that the service was provided in an 
inpatient hospital setting. You billed code 99316 (skilled nursing facility, discharge day management) with 
POS code 31, indicating that the service was performed in a skilled nursing facility.  However, records show 
that the patient was admitted to an inpatient hospital on May 5, 2022, through May 14, 2022.  This would mean 
that either the POS code you billed for code 99316 or the date of service of May 6, 2022, that you billed is 
incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99316 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99316 billed for date of service May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services and prescriptions provided on August 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services and prescriptions. You say that you were unable to find a 
doctor in Florida who would treat you, so you flew to see a provider you had seen before your move. The Plan 
denied your request. The Plan says unauthorized, out-of-network 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 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 medical services and prescriptions provided on 
August 8, 2022, 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 pneumatic compression device used after surgery on March 
15, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you provide this device to the 
facility and bill insurance when the facility uses it. You feel that this should be paid by the Plan. The Plan 
denied your request. The Plan says this was not authorized as required and cannot be billed separately from the 
surgical procedure. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device used after surgery on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay separately for items and services provided during an inpatient 
hospitalization from July 31, 2021, to September 16, 2021. 
 
You asked the Plan to pay separately for the inpatient items and services. You say that these items should be 
paid. The Plan denied your request. The Plan says the denied items and services are bundled into the payment 
for the hospitalization itself, and no separate payment is due. 
 
Medicare rules say that the payment for inpatient hospital services includes general routine services and special 
care unit services. Routine services include regular room, dietary and nursing services, minor medical and 
surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and 
facilities for which a separate charge is not customarily made.  
 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 separately for the inpatient items and services. 
Our reviewer says that these items and services are not eligible for separate payment. Our physician reviewer 
found you billed for the following items separately: 0.9% NACL irrigation solution, Extractor Pro Rx 7-6F (12-
15mm, 200cm), Hc insert straight catheter, Hc insert catheter temporary indwelling, Hydratome Rx (4.4F 
30mm W260cm GW), Kit catheter PICC FT Provena Solo (3cb L55 2 Lum), LCHG Blood draw, LCHG 
Glucose POCT, and Rx ERCP Cannula, tapered tip.  These items are considered general routine services and 
would not be reported separately from the inpatient hospitalization itself. 
 
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 inpatient items and services have not been met. Therefore, we decided that 
the Plan does not have to pay separately for items and services provided during an inpatient hospitalization 
from July 31, 2021, to September 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health (HH) services provided from January 7, 
2022, through February 5, 2022. 
 
You asked the Plan to pay for the HH services. You say that these services were billed correctly and were 
medically necessary. The Plan denied your request. The Plan says the reported admission date on the final 
claim is not appropriate based on the HH billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees continuing to receive HH services 
into 2022, an NOA must be submitted with the first day of the 2022 period of care as the admission date. All 
subsequent claims must also report the new 2022 admission date in order to link the claims to the NOA.  
 We looked at the file and Medicare rules. In this case, the final claim was not correctly billed with an 
admission date of January 7, 2022, as required. Based on this information, we decided that Medicare rules for 
coverage of the HH services have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health (HH) services provided from January 7, 2022, through February 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have stabilized medically and are ready for discharge from the hospital. You 
do not require skilled nursing and/or therapy services on a daily basis. You can receive services in a lower level 
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service April 8, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service April 8, 2022, billed with 
code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized for weakness and hyponatremia, and arterial blood gas 
(ABG) was consistent with acute on chronic hypercarbic respiratory failure. A nerve conduction study was 
abnormal and there is an elevated hemidiaphragm, but there is no detailed neurologic exam or specific 
neurologic diagnosis. It is unclear whether this enrollee has Chronic obstructive pulmonary disease (COPD), and if so, to what degree that may be contributing to the carbon dioxide (CO2) retention. The enrollee may 
benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
during sleep as an outpatient. If the enrollee does have a severe progressive neuromuscular disorder with 
associated respiratory compromise, a home ventilator may become necessary. But at this point criteria are not 
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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274 x4) provided 
on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency procedure and you paid 
cash for all the bills. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 11, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274 x4) 
provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns on tooth #8, 9, and 14 (D2740). 
 
You asked the Plan to pre-approve the crowns. You say that these services are medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 8, 2022. Therefore, 
we decided that the Plan does not have to pre-approve crowns on tooth #8, 9, and 14 (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for sepsis, urinary tract infection, pneumonia, renal failure, and congestive heart failure. 
There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided a in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.