Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78070 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 78070. You say that this service was reported correctly and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78070 is 1. The MAI value for this code is 2. You 2 units of this code, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 
78070 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 78070 
billed for date of service August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and all related supplies (A7035, A7036, A4604, A7030, A7039, E0562, A7028, A7029, A7031, 
A7032, A7033, A7038). 
 
You asked the Plan to pre-approve a CPAP device and all related supplies.. You say that the provider included 
the enrollee's records showing that his compliance was 80% from July 14, 2022, to August 12, 2022. The 
enrollee was diagnosed in 2011 with sleep apnea and he recently went for a sleep consultation with reports 
from his wife of excessive daytime sleepiness. He used a CPAP machine for several years but stopped and he 
does not remember why. The Plan denied your request. The Plan says the enrollee has a problem that affects 
his sleep. The request cannot be approved because the enrollee's records do not show a face-to-face visit with 
his doctor showing that he is still using his positive airway pressure machine after five years because it helps 
his symptoms. 
 
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 a CPAP device and all related supplies.. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
the CPAP device and related supplies at issue in this case meet all Medicare criteria for medically reasonable 
and necessary for the enrollee. Provided medical records do not document an in-person clinical re-evaluation 
by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved. 
 
 
 
 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 CPAP device and all related supplies. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and all related supplies (A7035, A7036, A4604, A7030, A7039, E0562, A7028, A7029, A7031, 
A7032, A7033, A7038).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 You asked the Plan to pre-approve the portable oxygen. You say that you are locked in your home and is 
unable to visit family due to lack of oxygen. The Plan denied your request. The Plan says the available medical 
records do not support that the enrollee meets the medically necessary criteria. 
 
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 portable oxygen. 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 the enrollee's present portable oxygen tanks do not 
last long enough for them to go out of the home. The enrollee reportedly uses a walker for mobility. The 
records do not clarify that the enrollee has tried and failed utilization of one (or more) light weight oxygen 
tanks (as offered by the health plan) carried in a rollator walker basket for portability needs. In addition, there is 
a safety concern for oxygen use in this case as the enrollee is reported to continue to smoke up to a pack of 
cigarettes per day in the setting of 3 liters continuous oxygen use.  
 
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 portable oxygen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for laboratory services provided on July 13, 2022. 
 
You asked the Plan to pay the full cost for laboratory services. You say that this was medically necessary. The 
Plan denied your request. The Plan says the allowed amount has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. 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 copayment for laboratory services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. You have been asked to pay a $20 copayment as part of the allowed amount. 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 pay the full cost for laboratory services provided on July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22612, 22867). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found interspinous devices are considered experimental. More research is needed to show safety and 
efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer placement (22612, 22867).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that the 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve safety shoes for lower-limb prostheses. 
 
You asked the Plan to pre-approve safety shoes. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says safety shoes are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shoes are denied as noncovered when they are 
put on over a partial foot prosthesis or other lower extremity prosthesis which is attached to the residual limb 
by other mechanisms. Based on this information, we decided that Medicare rules for coverage of safety shoes 
have not been met. Therefore, we decided that the Plan does not have to pre-approve safety shoes for lower-
limb prostheses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on July 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee sleeve (A4467) provided on June 22, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that fabric supports are not covered 
because they are non-reusable supplies; and are not rental-type items. 
 
While the fabric support may be appropriate in this case, neither the Plan nor Medicare offers coverage of these 
items. Therefore, we decided that the Plan does not have to pay for the knee sleeve (A4467) provided on  
June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you are looking for a second opinion and this provider has an excellent program. The 
Plan denied your request. The Plan says that your Plan does not cover out-of-network services rendered with 
the exceptions of the following: Emergency care or urgently needed services that you get from an out-of-
network provider. If you need medical care that Medicare requires our Plan to cover and providers in our 
network cannot provide this care you can get this care from an out-of-network provider. For these types of 
referrals, you must obtain authorization before seeking care. Renal dialysis services when you are temporarily 
outside the service area, or when prior authorized. The requested services are available in the community level 
in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental, and more research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
1, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that it is felt that 99285 correctly describes the 
level of care provided in this case. The Plan denied your request. The Plan says code 99284 more accurately 
describes the services 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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function.  
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 ED services as billed. Our reviewer says 
that the records do not support the use of code 99285 for this ED visit. Our reviewer found the enrollee 
presented to the ED complaining of dizziness/balance problems. The enrollee was hemodynamically stable 
with normal vital signs and unremarkable diagnostic studies. There was no sign of multisystem dysfunction, a 
condition that posed an immediate life-threatening threat, and no acute situation of a complex nature to support 
the level of care billed. 
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on August 1, 2022, billed with code 
99285.
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 would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF), home with home 
health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of this drug have 
not been satisfied. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of stage IIIc ovarian cancer that is tumor mutational burden-low, 
microsatellite instability stable and proficient mismatch repair disease. The Food and Drug Administration has 
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation.  No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) positron emission 
tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
disease (AD) and Frontotemporal Dementia (FTD).  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that Medicare covers FDG-PET 
scans for either the differential diagnosis of frontotemporal dementia (FTD) and Alzheimer's disease under 
specific requirements. The clinical documentation does not support that this enrollee's onset, clinical 
presentation, or course of cognitive impairment is such that FTD is suspected as an alternative 
neurodegenerative cause of the enrollee's cognitive decline. Specifically, symptoms such as social disinhibition, 
awkwardness, difficulties with language, or loss of executive function are not documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation (78608).