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

 
We decided that the Plan does not have to pay for refractions (92015) provided on September 21, 2022. 
 
You asked the Plan to pay for the refractions. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is a non-covered service.  
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 performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. This service was not provided as part of a routine eye exam. Based 
on this information, we decided that the Plan's rules for coverage of the refractions have not been met. 
Therefore, we decided that the Plan does not have to pay for refractions (92015) provided on September 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520) provided on August 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services (83520) provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that a home BiPAP is not appropriate for meeting this 
enrollees ventilatory requirements. The Plan denied your request. The Plan says the device to assist with 
breathing (noninvasive ventilator) requested does not meet the requirements for approval. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records document a diagnosis of chronic respiratory failure with obesity 
hypoventilation syndrome and obstructive sleep apnea. The provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive airway 
pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 not tried and failed the 
Plan's required drug, Venofer. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Feraheme 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 Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on July 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on June 4, 2022. 
 
You asked the Plan to pay for emergency room services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency room services provided on June 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that Botox is medically reasonable or necessary. Our physician reviewer found 
the enrollee has trigeminal neuralgia. The noted diagnosis is not an enumerated condition for which coverage is 
available under the rules. Therefore, the enrollee does not meet criteria for the requested Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visits provided from June 13, 2022, to June 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the office advised that they accepted your 
insurance. You say that you were scammed by the office. You also say that you should not be responsible for 
paying. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the outpatient visits provided from June 13, 2022, to June 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on March 11, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not supported by the records provided. 
 
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, the CPT Code Manual definition of code 99222 is initial hospital care, per day for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive exam; Medical decision making of moderate complexity. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, a comprehensive history is 
not supported by the provided records. There is a more appropriate code for the service provided. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 provided on March 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
24, 2021, to July 30, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 G93.41. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported. Our physician reviewer found that in 
this case, the enrollee had a baseline diagnosis of dementia. There was no clinical or laboratory evidence of 
metabolic encephalopathy. The review has determined that the documentation did not support diagnosis code 
G93.41 - metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 24, 2021, to July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73706 billed for date of service October 22, 
2022. 
 
You asked the Plan to pay for procedure code 73706. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73706 is bundled into payment for code 
74174. 
 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 73706 
is a column II code to column I code 74174. 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 73706 billed for date of service October 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided August 19, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that it is impossible for the enrollee to 
initiate and continue treatment without prescribed supplies A4595 as the device's design function for treatment 
require said supplies for regimen. The Plan denied your request. The Plan says the billed supply code cannot be 
verified. 
 
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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order 
number or details to corroborate the delivery ticket submitted. Of note, the proof of delivery is not itemized to 
indicate the specific supplies. 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 electrical 
stimulator supplies, 2 lead, per month (A4595) provided August 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
February 10, 2023. 
 
You asked the Plan to pre-approve SNF care after February 10, 2023. 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 February 10, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 after February 10, 2023, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after February 10, 
2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the band removal and port, lap sleeve gastrectomy and lap hiatal 
hernia repair. 
 
You asked the Plan to pre-approve the surgical procedure. You say that removal of the enrollee's adjustable 
gastric band, conversion to a sleeve gastrectomy, with concomitant repair of the hiatal hernia is in the enrollee's 
best interest and will significantly improve the enrollee's quality of life. The Plan denied your request. The Plan 
says that the request for band removal and port, lap sleeve gastrectomy and lap hiatal hernia repair is not 
medically necessary. 
 
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.  
 
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 surgical procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee meets all standard criteria for bariatric surgery (Centers for Medicare & 
Medicaid Services (CMS), American Society for Metabolic and Bariatric Surgery (ASMBS), International 
Federation for the Surgery of Obesity (IFSO) given morbid obesity and completion of a multidisciplinary 
evaluation. The enrollee underwent a lap band in 2007 with 30-pound weight loss which was regained. The lap 
band does not provide any hormonal or metabolic mechanism for weight loss and is generally no longer being 
offered for weight loss given lack of durable outcomes. This enrollee has failed multiple efforts at weight loss 
and would benefit from a metabolic bariatric procedure. Given that the lap band is a foreign device, it will need 
to be removed (band and port) as part of conversion to a metabolic bariatric procedure. 
 
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 surgical procedure have been met. Therefore, we decided that the Plan has 
to pre-approve the band removal and port, lap sleeve gastrectomy and lap hiatal hernia repair.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing of 15-21 drug classes (G0482) provided on 
August 24, 2022. 
 
You asked the Plan to pay for definitive drug testing of 15-21 drug classes. You say that this claim should be 
paid. The Plan denied your request. The Plan says that only 9 drug classes were tested. 
 
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, the CPT Code Manual definition of 
code G0482 is definitive drug testing of 15-21 classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the claim and 
confirmed that 15-21 classes of drugs were tested. Based on this information, we decided that Medicare rules 
for coverage of definitive drug testing of 15-21 drug classes have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing of 15-21 drug classes (G0482) provided on August 24, 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 14, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 procedure code 76705 billed for date of service October 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 1, 2022, to January 6, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG has been modified to 190.  
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.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that in this case, the enrollee has chronic hypoxic respiratory failure 
given her baseline oxygen need, however there is nothing to suggest that once she was treated in the ED she 
was appreciably worse than her baseline, even though she was subjectively dyspneic. No arterial blood gases 
were obtained. The review has determined that  the documentation did not support diagnosis codes J96.01 - 
acute respiratory failure, and R06.02 - shortness of breath.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 1, 2022, to January 6, 2022.