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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC). 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary because tanks on 
wheels are too heavy and bulky. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 a 
portable oxygen concentrator is not medically necessary because Medicare criteria are not met. This patient is 
recovering from pneumonia and was discharged on oxygen, including portable oxygen. The patient is 
requesting a POC because he is unable to handle the portable tanks. The records do not document that the 
SpO2 can be maintained more than 91% using an oxygen conserving device at 1 to 4 L/min. If that requirement 
is met, a POC would be considered 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 the concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the ranibizumab injections, the 
bevacizumab injections, and the ophthalmologist services provided from June 21, 2018, to September 28, 2022. 
 
You asked the Plan to waive the cost-sharing for the injections and ophthalmologist services. You say that you 
were not notified that there was a cost-share for these services. 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 of the total cost for in-network other Medicare Part B drugs, a $50 copayment for in-network 
Medicare-covered physician specialist services received in 2018 and 2019, and a $35 copayment for in-network 
Medicare-covered physician specialist services received in 2021 and 2022. 
 
You have been asked to pay a cost-share of $2714.70 for the injections ($13,573.57 allowed amount for 16 
injections x .20 = $2714.70). These items/services fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay a cost-share of $640 for the ophthalmologist services ($50 
copayment x 10 services in 2018 and 2019 = $500) ($35 copayment x 4 services in 2021 and 2022 = $140) 
($500 + $140 = $640). These items/services fall within the physician/practitioner services, including doctors 
office visits 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 cost-sharing for the ranibizumab 
injections, bevacizumab injections, and ophthalmologist services provided from June 21, 2018, to September 
28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation as to 
why radiofrequency ablation (RFA) is not the next step in therapy. Utilization limit also limits to 4 blocks per 
year. The request is not medically 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70496, Q9967, G1010, 70498) provided 
on April 26, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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 CPT code 70496, Q9967, G1010, & 70498 is not supported in the medical record. Specifically, 
the claim was billed with diagnosis codes I65.29: Occlusion and stenosis of unspecified carotid artery, and 
I65.23: Occlusion and stenosis of bilateral carotid arteries. Laterality was not properly reported. Based on this 
information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (70496, Q9967, G1010, 70498) 
provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 29806, 29826) provided to the 
enrollee on August 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes are not supported by the medical records. 
 
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 
the denied codes is: 
 
CPT 29806: 
 
Arthroscopy, shoulder, surgical; capsulorrhaphy 
 
CPT 29826: 
 
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with 
coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary 
procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite there was 
persistent instability with a lax anterior-inferior capsule and positive drive-through. Anterior-inferior 
capsulorrhaphy was performed with additional sutures and anchors. Therefore, the records do support that 
29806: arthroscopy, shoulder, surgical; capsulorrhaphy was rendered in this case. Additionally, the rocedure 
details cite that the subacromial space was debrided of all bursitis and osteophytes impinging on the rotator 
cuff. Therefore, the records do support that CPT 29826: arthroscopy, shoulder, surgical; decompression of 
subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when 
performed (list separately in addition to code for primary procedure) was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 29806, 29826) provided to the enrollee on August 16, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic laboratory services provided to the enrollee on July 25, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this does not meet the coverage requirements. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that per the National Comprehensive Cancer Network Guidelines on myeloproliferative disease from 
March 2022, this molecular testing would be advised. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
diagnostic laboratory services provided to the enrollee on July 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 8, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 
services 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 physician's services provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on September 01, 2022. 
 
You asked the Plan to pay for wound care services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care services 
provided on September 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory service provided on September 07, 2022. 
 
You asked the Plan to pay for laboratory service. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory service 
provided on September 07, 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 June 
14, 2022, to June 15, 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 there was no indication of acute on chronic 
(congestive) heart failure and there's no evidence of acute heart failure at the time of admission 
 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 DRG 266. 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, there was no clinical or laboratory evidence of acute on chronic diastolic congestive heart 
failure. The review has determined that the documentation did not support diagnosis code I50.33 - acute on 
chronic diastolic (congestive) heart failure. The records do not support DRG 266 in this case.  
 
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 June 14, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the gastroenterology telemedicine visit 
provided on October 20, 2022. 
 
You asked the Plan to waive the copayment for the telemedicine visit. You say that you were not told that there 
would be a charge for this service. 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 $45 
copayment for each specialist telemedicine visit. 
 
You have been asked to pay a $45 copayment for the telemedicine visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 gastroenterology telemedicine visit provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot provided on September 22, 2022. 
 
You asked the Plan to pay for a walking boot. You say that you are unable to obtain prior authorization at the 
time of service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a walking boot provided 
on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus); single lesion (11055) provided on July 28, 2022. 
 
You asked the Plan to pay for the routine foot care. You say that you have had this procedure done many times 
in the past. You also say that it has always been covered. The Plan denied your request. The Plan says routine 
foot care is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the paring or 
cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion (11055) provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the neuromonitoring services provided on February 2, 2022. 
 
You asked the Plan to pay for the physician services. You say that you are not sure what further information is 
necessary for the claim to be paid. The Plan denied your request. The Plan says that the provider requirements 
were not met at the time the services were rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the records do not support that the provider did not meet the 
requirements for coverage. This means that the Plan has not provided a valid reason for denying payment of the 
provided services. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for the neuromonitoring services provided on February 2, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the thorax (code 00400) provided on  
May 23, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the thorax. The Plan denied your request. The Plan 
says that this service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a rule to substantiate their denial. Therefore, we 
decided that the Plan has to pay for anesthesia for procedures on the thorax (code 00400) provided on  
May 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on May 28, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 15, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for the x-ray have not been met. 
Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on May 28, 2022.