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

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with Average 
volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is 
available upon request. The elements of the coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 10, 2021, to April 
13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient care at the DRG originally billed. You say that this diagnosis is 
supported in the medical record. The Plan denied your request. The Plan says the diagnosis of A41.51 (sepsis 
due to escherichia coli [e. Coli]) us not supported in the medical record, meaning that the principal diagnosis 
was N39.0 (urinary tract infection, site not specified), resulting in a different DRG being paid. 
 
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 the principal diagnosis of A41.51 (sepsis due to 
escherichia coli [e. Coli]). 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 care 
at the DRG originally billed. Our reviewer says that the diagnosis of A41.51 (sepsis due to escherichia coli [e. 
Coli]) is not supported in the medical record. Our physician reviewer found the enrollee was a 75-year-old 
male who presented to the facility with fever, nausea, vomiting, and weakness. The patient had a past medical 
history that included chronic obstructive pulmonary disease (COPD), urinary incontinence, and a 
prostatectomy. The patient was admitted and treated for a urinary tract infection and a COPD exacerbation. In 
the emergency room, initial vital signs showed a temperature of 96.8, heart rate of 110, respiratory rate of 22, 
blood pressure of 110/68 and a SpO2 of 93%. Laboratory data also revealed an elevated white blood cell count. 
The patient was noted to be alert and oriented x 3. Additional laboratory data on admission also revealed a 
creatinine of 0.85, a total bilirubin of 0.8, and a platelet count of 288. There was no clinical or laboratory 
evidence of sepsis.  
 
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 care provided from April 10, 2021, to April 13, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record indicates that you were 
successfully treated with bilevel positive airway pressure (BiPAP). The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with Average volume-assured pressure support (AVAPS) 
capability. The plan has indicated coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
March 14, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was receiving hospice benefits 
at the time of service. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care (99309) provided on March 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
January 17, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford the copayment. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 
copayment for each therapy visit.  
 
You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient Rehabilitation Services 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 physical 
therapy (PT) services provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided from January 10, 
2022, to January 25, 2022. 
 
You asked the Plan to pay for the services provided. You say that you do not see any incorrect modifiers. The 
Plan denied your request. The Plan says the service was billed with an inappropriate combination of modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We looked at the file and the rules. The services at issue were billed with more than the GP modifier. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient therapy services provided from 
January 10, 2022, to January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. 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. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trans-arterial radioembolization (TARE). 
 
You asked the Plan to pre-approve TARE. 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. 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 TARE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Y-90 microspheres/radioembolization is medically necessary for non-colorectal cancer liver 
metastases when other acceptable standard therapies are unlikely to be effective (i.e. chemotherapy  per 
NCCN guidelines). As the enrollee is a candidate for standard therapy, it is not believed that radioembolization 
would be within accepted standards 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 TARE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve trans-arterial radioembolization (TARE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
January 11, 2022. 
 
You asked the Plan to pay for procedure codes 99140 and 99100. You say that the medical records support 
payment. The Plan denied your request. The Plan says procedure codes 99140 and 99100 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99140 and 99100 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99140 and 99100 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99140 and 99100 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) provided February 23, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the physicians order for the DME equipment 
follows all Medicare guidelines and supports medical necessity to be reprocessed and paid. The Plan denied 
your request. The Plan says the services are not documented int the enrollee's medical records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, and relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Ozempic.  
 
Benefits for Ozempic 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 genetic testing provided on May 11, 2021, billed with 
codes 81401, 81225, 81227, 81226, 81230, 81231, 81241, 81291, 81240, 81328 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 11, 2021, 
billed with codes 81401, 81225, 81227, 81226, 81230, 81231, 81241, 81291, 81240, 81328 and 81355.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from March 29, 2021, through 
April 6, 2021, at DRG 640. 
 
You asked the Plan to pay for inpatient services at DRG 640. You say that the claim was underpaid and should 
be reprocessed for additional payment per the contract. The Plan denied your request. The Plan says diagnosis 
codes I50.33 and E87.1 are not supported resulting in a DRG change from 640 to 644. 
 
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 with principal diagnosis code E87.1, defined as hypo-osmolality 
and hyponatremia and secondary diagnosis code I50.33, defined as acute on chronic diastolic (congestive) heart 
failure. 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 inpatient services at DRG 640. Our 
reviewer says that the documentation does not support diagnosis codes E87.1 and I50.33. Our physician 
reviewer found the medical record has no evidence of clinical symptoms or findings on the physical exam 
consistent with the diagnosis billed.  
 
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 services provided from March 29, 2021, through April 6, 2021, at DRG 640.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for dates of service November 
3, 2021, to December 27, 2021. 
 
You asked the Plan to pay for procedure code S0020. You say that you do not believe you were paid 
sufficiently for these services. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for dates of service November 3, 2021, to December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022 billed with 
codes 81479-59. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022 billed with codes 81479-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for home health services provided from  
February 7, 2022, to March 13, 2022. 
 
You asked the Plan to reimburse you for home health services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 reimburse you 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 reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for home health services provided from 
February 7, 2022, to March 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93458 billed for date of service August 2, 
2021. 
 
You asked the Plan to pay for procedure code 93458. The Plan denied your request. The Plan says payment for 
code 93458 is bundled into payment for code 33361. 
 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 93458 
is a column II code to column I code 33361. 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 93458 billed for date of 
service August 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan must waive the coinsurance charged for these services since they have insufficiently 
explained what services are covered and non-covered in the case file and the Explanation of Benefits.  
 
You asked the Plan to waive this coinsurance. You say that you do not understand the cost share that is being 
applied. The Plan denied your request. The Plan says that this coinsurance was applied correctly. 
 
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 complete information 
regarding their decision. There is insufficient information in the case file to substantiate the Plans denial. The 
Plan documents do not adequately explain the non-covered services listed on the Explanation of Benefits. The 
Plan does state these services were authorized and the Plan contract quotes out of network benefits. As it 
appears you followed the Plan rules in obtaining these services, the Plan is required to fully explain what each 
charge was for and what, if anything, was not covered and explain why. As the Plan has not appropriately 
explained how the coinsurance was determined, it is our decision that the Plan must waive the coinsurance 
charged for chiropractic services provided on January 6, 2022.  
 
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.