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

 
We decided that the Plan does not have to pay for the Repair of 2 transvenous electrodes for permanent 
pacemaker or implantable defibrillator (33220) provided on June 9, 2022. 
 
You asked the Plan to pay for procedure code 33220. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the file shows that the provider did not bill as required 
by Medicare coding guidelines. Procedure code 33220 was billed with POS 11 and per Medicare guidelines, 
contractors shall deny claims for ICD services when the service is not rendered to an inpatient or outpatient of a 
hospital. Therefore, we decided that the Plan does not have to pay for the Repair of 2 transvenous electrodes for 
permanent pacemaker or implantable defibrillator (33220) provided on June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure cuff (A4670). 
 
You asked the Plan to pre-approve an automatic blood pressure cuff. You say that the item is necessary. The 
Plan denied your request. The Plan says the requested item is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an automatic blood pressure cuff (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a radiation therapy visit provided on 
February 25, 2022. 
 
You asked the Plan to waive the coinsurance for a radiation therapy visit. You say that your max out-of-pocket 
had already been met and you should not owe anything. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered therapeutic radiology services.  
 
You have been asked to pay a coinsurance of $196.02, which is 20% of the allowed amount for a radiation 
therapy visit ($980.09 allowed x 20% = $196.02). This item/service 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 coinsurance 
for a radiation therapy visit provided on February 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 23, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless they are authorized by the Plan before the services are provided. 
 
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 
service 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 psychotherapy provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP () provided on March 25, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP. You say that the services should be covered as you 
disagree with the charges. 
 The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the CPAP. This item/service falls within the Durable 
medical equipment (DME) and related 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 
coinsurance for a CPAP () provided on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing on June 15, 2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day, per provider, for Medicare-covered lab services. Covered services include, but are not 
limited to laboratory tests. 
 
You have been asked to pay a $10 copayment for lab testing. This item/service 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 lab testing on June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that you are appealing this denial. The 
Plan denied your request. The Plan says this is not medically necessary, because without magnetic resonance 
imaging (MRI) results the Plan does not know what may be the cause of the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are covered when history, 
physical examination, and radiological imaging support a 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 epidural steroid injections. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested epidurals. Our physician 
reviewer found there is no imaging of the spine documented. Therefore, this request is not considered 
medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided 
from November 24, 2021, to November 26, 2021. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you are requesting 
to appeal the claim because you do not agree with the copayment assessed. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for days 1 to 7 and $0 copayment per day for days 8 to 90 for each inpatient hospital stay.  
 
 
  You have been asked to pay a $500 copayment for an acute inpatient hospital stay ($250 per day x 2 days = 
$500). This item/service falls within the Inpatient Hospital Care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an acute inpatient hospital stay provided from November 24, 2021, to November 
26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right radiofrequency ablation (RFA) at L3 to L4 (64635, 
64636). 
 
You asked the Plan to pre-approve RFA. You say that the enrollee's spinal fusion was at L4 to L5. You also say 
that the RFA is being requested for a different level. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is considered medically reasonable and 
necessary after the patient has had at least two medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee has only received one medial branch block (MBB). The reviewer found that only 60% pain 
relief was reported. The reviewer found that Medicare guidelines require two MBBs before RFA will be 
considered. Therefore, the requested RFA is not medically 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve right radiofrequency ablation (RFA) at L3 to L4 (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305) provided on March 29, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 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 the testing services were not billed with a modifier suitable for payment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305) provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and a portable 
oxygen concentrator, rental (E1392). 
 
You asked the Plan to pre-approve oxygen equipment. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because your records show 
you do not have oxygen saturations at or below 88. 
 
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 oxygen equipment Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD and bronchiectasis. 
The records include two separate measurements of pulse oximetry at rest, 93% and 91%, presumably breathing 
room air. These do not meet criteria for oxygen need (less than 89%). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an oxygen concentrator, single delivery port, capable of delivering 85 percent or 
greater oxygen concentration at the prescribed flow rate (E1390) and a portable oxygen concentrator, rental 
(E1392).
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. You say that the enrollee has serious life-threatening constellation 
acute medical problems that have left them at a functional status below their baseline. You say that the enrollee 
requires close daily oversight of care by a physician in an inpatient setting. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and the enrollee can receive care in another setting. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77373-TC and 77336-TC billed for dates of 
service May 11, 2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure codes 77373 and 77336. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
were reported with a modifier which may not be used with these codes. Therefore, Medicare billing criteria are 
not met in this case. 
 The Plan must follow Medicare rules. Medicare rules say that modifiers 26 and TC cannot be used with CPT 
codes which have a PC/TC indicator of 3.  
 
We looked at the file and Medicare rules. Codes 77373 and 77336 both have a PC/TC indicator of 3. This 
means that it was inappropriate to report these services with the TC modifier. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 77373 and 77336 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 77373-TC and 77336-TC billed for dates of 
service May 11, 2022, to May 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits. 
 
You asked the Plan to pre-approve additional home health physical therapy visits. You say that you need more 
therapy sessions. The Plan denied your request. The Plan says this request is not medically reasonable or 
necessary for additional visits due to the fact that after receiving seven home health physical therapy visits, 
there were no appreciable improvement in functional status. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health physical therapy 
visits. Our reviewer says that additional home health physical therapy visits are not medically necessary. Our 
physician reviewer found you do not have documented ongoing, skilled physical therapy needs.  You have 
received ample time to assess durable medical equipment needs, learn a home exercise program and provide 
caregiver education. You are not expected to have significant functional improvement due to your progressive 
neurologic condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional home health physical therapy visits.
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 January 8, 2022, to February 2, 2022. 
 
You asked the Plan to pay for SNF care. You say that you were required to stay due to contracting COVID-19 
while at the SNF. The Plan denied your request. The Plan says the health plan has no contractual obligation to 
cover services that are not covered by Medicare.  
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 there were no identifiable skilled nursing service needs. There were no 
identifiable skilled therapy service needs. You did not require skilled nursing or therapy services on a daily 
basis. You did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 January 8, 2022, to February 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered when used as a bi-level positive airway pressure (BiPAP) 
device. 
 
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 requested home ventilator is not medically necessary. Our physician reviewer found the records do not 
document a diagnosis of chronic obstructive pulmonary disease (COPD) or thoracic restrictive disease. A 
diagnosis of critical illness myopathy is listed, but there are no objective findings to support this. The enrollee 
may benefit from a bi-level positive airway pressure (BiPAP) device, but Medicare does not cover a home ventilator when used as BiPAP. 
 
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 (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for dates of service March 14, 
2022, to March 16, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that this should be covered. 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 S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for dates of service March 14, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 92960. 
 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 93010 
is a column II code to column I code 92960. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 25, 2022.