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

 
We decided that the Plan does not have to waive the coinsurance for an at home oxygen equipment provided 
from December 9, 2021, to February 9, 2022. 
 
You asked the Plan to waive the coinsurance for an oxygen equipment. You say that you should not have a 
coinsurance for this item. The Plan denied your request. The Plan says the coinsurance applied was 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $120.51 resulting in a 
coinsurance amount of $24.10 ($120.51 x 20% = $24.10) ($24.10 x 3 visits = $72.30). 
 
You have been asked to pay a $72.30 coinsurance for an oxygen equipment. an oxygen equipment falls within 
the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an at home oxygen equipment provided from December 9, 2021, to February 9, 
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 services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of the recertification. 
 
The Plan must follow Medicare rules. Medicare rules say that the oxygen Recertification is required 12 months 
after Initial Certification. 
 
There is no documentation of a physician visit for a recertification in this case. The necessity of this item has 
not been proven by a physician. 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 a portable 
oxygen concentrator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.  
 
 
 Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography, of the 
maxillofacial area; without contrast material (70486) provided on April 7, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $100 
copayment for diagnostic radiology (computed tomography (CT), magnetic resonance imaging (MRI), positron 
emission tomography (PET) scan, etc).  
 
You have been asked to pay a $100 copayment for the diagnostic radiology service provided. 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 computed tomography, of the 
maxillofacial area; without contrast material (70486) provided on April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopy services provided to the enrollee on August 17, 
2021. 
 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 29824: 
 
Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 
 
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) 
 CPT 29827: 
 
Arthroscopy, shoulder, surgical; with rotator cuff repair 
 
CPT 29828: 
 
Arthroscopy, shoulder, surgical; biceps tenodesis 
 
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 not supported by the medical records. Our reviewer found that the records do not support that the 
denied codes were actually rendered in this case. The enrollee was being treated for strain of muscle and tendon 
of the rotator cuff of the left shoulder; other sprain of the left shoulder; strain of muscle, fascia and tendon of 
long head of biceps, left arm. He underwent a left shoulder arthroscopy, rotator cuff repair, distal clavicle 
excision, subacromial decompression, labral debridement, and biceps tenodesis on 8/17/21. However, the 
operative note indicates that there was a dissection carried out, down through the skin and subcutaneous 
tissues, along with associated procedures. This indicates that open procedures were performed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for arthroscopy services provided to the enrollee on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that chemotherapy has caused neuropathy in your 
feet. The Plan denied your request. The Plan says you do not have diabetes. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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. Our reviewer says that the 
services are medically necessary. Our physician reviewer found clinical documentation states you have medical 
monitoring needs which would require the skill of a professional registered nurse and evaluating therapist states 
that you require daily skilled therapy for new functional impairments and recommends a skilled nursing facility 
setting. From a practical matter, clinical documentation shows that daily skilled services in a skilled nursing 
facility are 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a supply allowance (K0553) and receiver (K0554) for a Freestyle 
Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a supply allowance and receiver. The Plan denied your request. The Plan 
says that there is no additional information showing the number of insulin injections per day. The Plan also 
says the medical necessity criteria are not met. 
 
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 did not provide a copy of any medical records for this case. We asked 
for medical records, but they were not received, nor that the Plan attempted to obtain them. The provided 
information shows that the enrollee has been diagnosed with Type 1 Diabetes. Without medical records, we 
cannot determine that the criteria for coverage have not been met in this case. Therefore, we decided that the 
Plan has to pre-approve a supply allowance (K0553) and receiver (K0554) for a Freestyle Libre continuous 
glucose monitor (CGM).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed on January 27, 2022. 
 
You asked the Plan to pay for procedure code 93355. You say that code 93355 is not included in the primary 
procedure and the modifier is correct. You say that the claim should be sent back to process for payment. The 
Plan denied your request. The Plan says a modifier cannot be billed to bypass the code pair edit. 
  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 93355 
is a column II code to column I code 00560 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93355 billed on January 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services (77435, 77263) provided 
on October 18, 2021, and November 1, 2021. 
 
You asked the Plan to waive the copayment for the radiology services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $60 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $120 copayment for two radiology services ($60 x 2 = $120). Radiology services 
fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for radiology services (77435, 77263) provided on October 18, 2021, 
and November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services are not covered. 
 
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, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested repairs of a powered mobility 
device. Per the Plans guidelines, secondary wheelchairs and related equipment that have been provided as 
medically necessary, their repair and replacement are allowed according to the criteria for repair and 
replacement of single/initial wheelchairs and related equipment. The file shows that the Plan made no attempts 
to obtain medical records from the treating/ordering provider to determine if the enrollee meets this criterion. 
 
Furthermore, a power wheelchair is not considered a duplicative item to a manual wheelchair. The Medicare 
criteria needed for approval of a manual wheelchair are different than the criteria needed for a power 
wheelchair. The enrollee states that her current manual wheelchair is not suitable to meet her needs. The file 
does not show that the Plan made any attempts to obtain information from the ordering/treating provider to 
determine if the enrollees current manual wheelchair meets the enrollees mobility related needs.  
 
Therefore, we decided that the Plan has to pre-approve power wheelchair repairs.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CPAP device have been met. 
Specifically, the available medical documentation is too old to establish current and ongoing medical necessity 
for requested item. Therefore, we decided that the Plan does not have to pre-approve a continuous positive 
airway pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded 99223 
provided on July 26, 2021. 
 
You asked the Plan to pay for the evaluation and management services as billed. You say that the 
documentation supports payment for the services as billed. The Plan denied your request. The Plan says the 
criteria for billing the evaluation and management code have not been satisfied. 
 
The Plan follows Medicare rules. Medicare rules say that for evaluation and management services, providers 
must bill Current Procedural Terminology (CPT) codes based upon the content of the service provided.  
 
In this case, the CPT Code Manual definition of code 99223 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 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 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 evaluation and management services as 
billed. Our reviewer says that the billed evaluation and management code is not supported by the medical 
record. Our physician reviewer found the review indicates that the enrollee was a 64-year-old with a history of 
coronary artery disease, status-post coronary artery bypass graft surgery in 2020, hypertension, hypersensitivity 
lung disease, and ischemic cardiomyopathy. They presented to the emergency department on July 26, 2021, 
with chest pain and upper abdominal pain. The evaluation revealed slightly elevated troponins. He was 
admitted and evaluated by Cardiology and Gastroenterology. The reviewed documentation indicates that the 
evaluation did not document problem(s) requiring admission that were of high severity. The review has 
determined that the documentation did not support payment for CPT 99223. 
 
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 evaluation and management services as billed have not been met. Therefore, 
we decided that the Plan does not have to pay for the evaluation and management services coded 99223 
provided on July 26, 2021.