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

 
We decided that the Plan has to pay for the nebulizer, with compressor (E0570) purchased August 23, 2021. 
 
You asked the Plan to pay for the nebulizer, with compressor. You say that the Plan paid for the medication 
that was used in the nebulizer. You do not understand why the nebulizer would not be covered as well. The 
Plan denied your request. The Plan says that this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  In this case, the Plan denied that this item is not covered by Medicare. However, per LCD L33370, a small 
volume nebulizer (A7003, A7004, A7005), and related compressor (E0570) are considered for coverage when 
it is reasonable and necessary to administer the following FDA-approved inhalation solutions listed above. The 
Plan did not provide any records, nor is there any documentation indicating that the Plan requested records. It is 
noted that the medication was approved, however there are no notes showing what medication was approved. 
The Plan has not provided enough information to substantiate their reason to continue to deny.  We looked at 
the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
nebulizer, with compressor have been met. Therefore, we decided that the Plan has to pay for the nebulizer, 
with compressor (E0570) purchased August 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision or destruction (eg, laser), intranasal lesion 
(30117). 
 
You asked the Plan to pre-approve the intranasal procedure. You say that your specialsit would not ask to have 
a procedure done if you did not need it. Your specialists advised that because the medication is not working he 
wants to do the Cryo procedure so you can stop using the medication. The Plan denied your request. The Plan 
says cryotherapy or radiofrequency therapy, to decrease the symptoms of allergic or nonallergic rhinitis is 
considered investigational and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intranasal procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the excision or destruction (eg, laser), intranasal lesion (30117).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care from August 27, 2021, to  
August 31, 2021. 
 
You asked the Plan to pay for inpatient hospital care from August 27, 2021, to August 31, 2021. You say that it 
is the Plan's responsibility to pay for post-stabilization care. The Plan denied your request. The Plan says the 
facility did not seek authorization for post-stabilization care until August 30, 2021, at 1:13pm (two days after 
the facility admitted the enrollee to inpatient status.)  The enrollee was stable in the emergency room. The Plan 
says that they approved observation care only. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 hospital care from August 27, 
2021, to August 31, 2021. Our reviewer says that the records do not show that coverage criteria of post-
stabilization care were met. Our physician reviewer found the enrollee was hemodynaimcially and 
neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for admission 
after the emergency room evaluation. There was no documentation provided indicating that the post-
stabilization care services at the non-Plan facility were medically necessary and reasonable. The treating 
physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for 
transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care from August 27, 2021, to August 31, 2021, have not been 
met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care from August 27, 2021, 
to August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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 July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on 
October 12, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that an ultrasound is a simple 
test like an X-ray, which is a $30 copayment. The Plan denied your request. The Plan says the copayment 
amount charged ($50) is correct. 
 
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 $50 
copayment for each Medicare-covered diagnostic radiology service in an office setting or imaging center.  
 
You have been asked to pay a $50 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic ultrasound provided on October 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 9, 2021, to October 9, 2021. 
 You asked the Plan to pay for the SNF services.. You say that these services should be covered by Medicare. 
The Plan denied your request. The Plan says criteria for SNF admission were not met. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient did not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF during the dates in question. The 
documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing 
SNF need during the dates in question. The patient's functional level did not require skilled therapy services 
with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment in a SNF from September 9, 2021, to October 9, 2021. The 
patient did not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF September 9, 2021, to October 9, 2021. As a practical matter this patient did not require 
the necessary services on an inpatient basis, in a skilled nursing facility setting September 9, 2021, to October 
9, 2021. 
 
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 SNF services. have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from September 9, 2021, to October 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the vision services provided on  
December 2, 2021. 
 
You asked the Plan to pay additionally for the vision services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says the claim that includes the medical eye 
exam with code 92014 has been reprocessed to pay, leaving you responsible for a $25 copayment per page 83 
of the Evidence of Coverage. The refraction service with code 92015 is covered under your supplemental 
vision benefit and is only covered when provided by a participating network optical provider. 
 
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 $25 
copayment for Medicare-covered vision services. In this case, the file shows that the claim that includes the 
medical eye exam with code 92014 has been reprocessed to pay, leaving you responsible for a $25 copayment 
per page 83 of the Evidence of Coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network optical provider. The refraction service 
with code 92015 is covered under your supplemental vision benefit and is only covered when provided by a 
network optical provider. Your provider was not a network optical provider on the date of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay additionally for the vision services 
provided on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the hip provided on November 
29, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you do not understand why you were 
billed again after paying $20. 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 $45 
copayment for basic radiological services provided in a specialist's office.  
 
You have been asked to pay a total of $43.10, which is less than the $45 copayment for the X-rays. The X-rays 
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for X-rays of the hip provided on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a complete exam of the visual system 
(92004) and an ultrasound of the cornea performed to determine thickness (76514) provided on  
November 17, 2021. 
 
You asked the Plan to waive the copayment for an eye exam and an ultrasound of the cornea. You say that the 
copayment is supposed to be paid by the Plan due to your diabetic condition. The Plan denied your request. The 
Plan says the cost-share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  The Plan contract also says that enrollees must pay a $225 copayment for Medicare-covered diagnostic 
radiology services. 
 
You have been asked to pay a $56.29 copayment for an eye exam and an ultrasound of the cornea ($45 
copayment for eye exam + $11.29 copayment for ultrasound = $56.29). The ophthalmology services at issue 
fall within the Vision Care and Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
categories. Since you are being asked to pay less than the required $225 copayment for the ultrasound, 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 a complete exam of the visual system (92004) and an 
ultrasound of the cornea performed to determine thickness (76514) provided on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 14, 2021, to October 13, 2021. 
 You asked the Plan to pay for the SNF services. You say that these services should be covered by Medicare. 
The Plan denied your request. The Plan says the the dates of service in question, the enrollee no longer required 
SNF care. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the 
hospital, the enrollee had stabilized medically.  The enrollee did not require any skilled nursing or rehab 
services on a daily basis at an inpatient level of care.  He was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
self-care tasks.  The enrolee did not require skilled therapy to establish a safe and effective maintenance 
program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care at the time of discharge from the hospital. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube.  He was medically stable without any acute 
exacerbations of chronic medical problems.  His physical function was at or near his baseline and he could 
have received further services 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from September 14, 2021, to  
October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for inpatient hospital services provided from September 5, 
2020, to September 9, 2020. 
 You asked the Plan to pay more for the inpatient hospital services. You say that the diagnosis related group 
(DRG) billed was appropriate. The Plan denied your request. The Plan says the diagnosis of A41.9 is not 
supported in the medical records, so the DRG billed was also not supported. 
 
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 diagnosis code A41.9 (sepsis, unspecified 
organism). 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 more for the inpatient hospital services. 
Our reviewer says that diagnosis A41.9 is not supported in the medical records. Our physician reviewer found 
this patient has a history of chronic kidney disease, pulmonary hypertension, and congestive heart failure. The 
patient presented to the emergency room with complaints of shortness of breath. The doctor says that while this 
patient's presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening 
organ dysfunction due to a dysregulated host response to infection.  
 
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 
more for inpatient hospital services provided from September 5, 2020, to September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on September 29, 
2021. 
 
You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on September 29, 2021.
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 care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF 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 while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that the sleep study is medically necessary. The Plan 
denied your request. The Plan says that a repeat sleep study is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study is covered for symptoms or complaints 
of obstructive sleep apnea. 
 
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 sleep study. Our reviewer says that 
the enrollee has a historical diagnosis of OSA. They need replacement equipment, but no prior test results are 
otherwise available. They are suspected of having OSA, which is an indication for which the requested service 
is 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 a sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a sleep study.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you have been wearing 
compression stockings since 2013 and cannot afford them now. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.