Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit with an 
Optometrist provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you were at the 
appointment for five minutes and would not have gone if you knew they were charging you $45. You also say 
that it should have been covered under the initial surgery. The Plan denied your request. The Plan says the 
copayment amount you are being charged 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 $45 
copayment for each Medicare-covered exam for Vision care.  
  
You have been asked to pay a $45 copayment for each Medicare-covered exam to diagnose and treat diseases 
or conditions of the eye for the outpatient office visit. The outpatient office visit falls within the Vision 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 the outpatient office visit with an 
Optometrist provided on December 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from April 27, 2021, 
to May 25, 2021. 
 
You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says the 
non-contracted provider did not submit the RAP claim for services for dates of service April 27, 2021, to May 
25, 2021 until August 3, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from April 27, 2021, to May 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 5, 
2020. 
 
You asked the Plan to pay for home infusion therapy (S9328). You say that the attached medical records 
support the processing of this claim. The Plan denied your request. The Plan says the billed code is not valid 
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 CPT code. 
 
We find that CPT code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy (S9328) have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy (S9328) provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for online fitness classes. 
 
You asked the Plan to pay for online fitness classes. You say that you called before submitting and was advised 
you would be reimbursed for this. The Plan denied your request. The Plan says online classes are not covered 
under the Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only in a qualified health club or fitness facility. 
 
The Plans rules for coverage of gym benefits have not been met because online fitness classes are not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for online fitness classes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says an evaluation for respiratory therapy can be covered. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found a portable 
oxygen concentrator is considered not medically necessary because Medicare criteria are not met. You have 
chronic obstructive pulmonary disease and interstitial lung disease, and was prescribed home oxygen at 
discharge from the hospital in December 2021. A portable tank system was provided which you are unable to 
use because you require two canes or a walker to ambulate. However, the records do not show that you are able 
to maintain an SpO2 of at least 91% while using an oxygen conserving device with a flow rate of 1 - 4 L/min. 
You also need updated oxygen qualification. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation and extraction to be provided by a 
periodontist. 
 
You asked the Plan to pre-approve the oral evaluation and extraction. You say that you went to a general 
dentist and are being asked to pay $764.00 plus an additional $255.00 versus the periodontist, who is asking for 
$550.00. The Plan denied your request. The Plan says the supplemental Dental Services benefit of your 
contract only provides coverage for dental services when performed by a participating general dentist. The Plan 
also says that dental services performed by a periodontist are not covered. 
 
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, the requested items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an oral evaluation and extraction to be provided by a periodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
You asked the Plan to pre-approve the requested device. You say that this walker can significantly improve 
your quality of life. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The file shows that you currently use a standard walker. Equipment 
for added convenience is not covered. 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 pre-approve an upright walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable gaseous oxygen contents for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
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 the services. Our reviewer says that the 
requested ervices are not considered medically reasonable and necessary in this case. Our physician reviewer 
found "portable gaseous oxygen contents" is considered not medically necessary because the contents are 
included in the portable gaseous oxygen system, which has been approved.  The stationary oxygen concentrator 
has also been approved. The denial of the contents is upheld because it is duplicative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve portable gaseous oxygen contents for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4Kscore testing.  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has elevated prostate 
specific antigen (PSA). This was his first PSA test, and his PSA level measured 12.1. The PSA level is not less 
than 10 ng/mL; therefore, the criteria for coverage are not met and the testing is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4Kscore testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 17, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 28, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider. 
 
You asked the Plan to pay for dental services. You say that you needed an emergency root canal. You say that 
you had no idea the dentist was an opt-out provider. The Plan denied your request. The Plan says the rendering 
dentist has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until April 11, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet blocks. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat facet injections are covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and previously had bilateral lumbar 
radiofrequency ablation (RFA) with 50 percent pain relief for only two weeks. There is no indication to repeat 
diagnostic blocks after failed RFA. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat facet blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) provided February 28, 2022. 
 
You asked the Plan to provide additional payment for the crown and core buildup. You say that these services 
were necessary and difficult to obtain due to the pandemic. The Plan denied your request. The Plan says you 
have exhausted your dental benefit and no further payment from the Plan is due. 
 
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. The Plan covers the crown and 
core buildup up to a $550 annual maximum payment.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
service provided February 28, 2022, you had $438 remaining in your annual maximum payment. This amount 
was applied to the services. You have been asked to pay the remaining amount above the maximum. Based on 
this information, we decided that the Plan's rules for coverage of the crown and core buildup have not been 
met. Therefore, we decided that the Plan does not have to provide additional payment for the crown - 
porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided February 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied tie down for a wheelchair (K0108). 
 
You asked the Plan to pre-approve the unoccupied tie down for a wheelchair. You say that you need the 
electric wheelchair for life sustainability. The Plan denied your request. The Plan says the unoccupied tie down 
does not serve a medical purpose, is not appropriate for use in the home, and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an unoccupied tie down for a wheelchair (K0108).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 5, 2022. 
 
You asked the Plan to pre-approve SNF care after May 5, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 after May 5, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation 
does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The 
enrollee's functional level does 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. 
 
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 after May 5, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee evaluated for use of a portable oxygen concentrator but could not 
maintain the required oxygen saturation. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that during 
the testing on 2/18/22, the enrollee's SpO2 during ambulation was 90%, while on oxygen via the concentrator. 
The criteria require maintenance of at least 91%. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator for the enrollee.