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

 
We decided that the Plan does not have to pre-approve a knee orthosis represented by code K1833. 
 
You asked the Plan to pre-approve the knee orthosis. You say that the enrollee has pain which started after 
getting off of a piece of farm machinery at home. You say that the documentation shows that the enrollee has 
ongoing pain and instability related to muscle spasms, which have compromised his stability and performance 
of activities of daily living. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis with adjustable knee joints is covered 
for certain medical 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 the knee orthosis. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has not had recent 
surgery or a recent injury.  The documentation doesnt support that the joint is unstable or that there is joint 
laxity.  The requested knee orthosis is not 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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis represented by code K1833.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device (E0650) provided 
October 27, 2021 to November 7, 2021. 
 
You asked the Plan to pay for the intermittent limb compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for preventative use. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee was actively being treated for lymphedema and/ or chronic venous 
insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an 
intermittent limb compression device (E0650) provided October 27, 2021 to November 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you believe that these charges are 
appropriate for the level of care provided. The Plan denied your request. The Plan says procedure code 99072 
is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided from September 
13, 2021, to September 23, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you feel you should not be 
responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received therapeutic/chemotherapy injection on the dates of service at issue in 
this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
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 Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $1373.51. The Part B drugs fall 
within the Medicare Part B Prescription Drugs 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 the Part B drugs provided from September 13, 2021, to September 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, mechanical traction therapy, physical therapy 
treatment, and neuromuscular re-education provided on February 10, 2022, to March 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit, mechanical traction therapy, physical therapy treatment, and 
neuromuscular re-education. You say that the services were necessary. The Plan denied your request. The Plan 
says you must use a network provider to receive coverage for services. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit, mechanical traction therapy, 
physical therapy treatment, and neuromuscular re-education provided on February 10, 2022, to March 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 4, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Aranesp. Our reviewer says that 
Aranesp is not reasonable and necessary for the enrollee. Our physician reviewer found there is no 
documentation of trial and failure of Retacrit or Procrit. Our reviewer also found that the documentation does 
not support that Retacrit or Procrit would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion device. 
 
You asked the Plan to pre-approve a Superion device. You say that the requested treatment is medically 
necessary and appropriate for this stage of the enrollee's disease progression. You say that the insertion of a 
lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. The 
Plan denied your request. The Plan says the requested procedure is experimental and investigational. 
 
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 Superion device. Our reviewer says 
that a Superion device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Superion device is experimental. 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 a Superion device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Superion device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on April 3, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you would like to appeal the denial of the claim. The Plan 
denied your request. The Plan says this is a duplicate claim and the claim is not supported by the 
documentation received. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 x-ray provided on April 3, 2022, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollees wife is not sure that she can provide 
the assistance that the patient needs at home. The Plan denied your request. The Plan says Medicare criteria for 
skilled nursing facility are not 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 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on August 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical period. 
 
We looked at the file and Medicare rules. Procedure code 49440 was billed within 10 days of the minor 
surgical procedure billed with code 36558 on July 30, 2021. Payment for this procedure is included in the 
global surgical package. Therefore, we decided that the Plan does not have to pay for the surgical services 
rendered on August 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on April 15, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you should only be 
responsible for a copayment. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 26, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the claim was 
received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for physician's services was not filed until May 5, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for physician's services provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 6, 2021, 
to November 12, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this diagnosis is 
supported in the medical record. The Plan denied your request. The Plan says the billed principal diagnosis of 
A41.9- Sepsis, unspecified organism, is not supported in the medical records. 
 
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 a principal diagnosis of A41.9- Sepsis, unspecified 
organism. 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 services at the DRG 
originally billed. Our reviewer says that the billed principal diagnosis of A41.9- Sepsis, unspecified organism, 
is not supported in the medical records. Our physician reviewer found the documentation supported an 
admission for type 2 diabetes mellitus with ketoacidosis. From the information that was received, 
documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis is documented on 
progress notes and discharge summary, the supporting medical record documentation was not found within the 
record. The patient found to have leukocytosis and hypertension and was admitted for evaluation and 
management of persistent vomiting. The patient's laboratory values on admission revealed platelet of 304; UA 
notable for bilirubin; creatinine of 1.20. Glasgow coma scale of 15 and urine output of 620 ml/day. Although 
the the hospital documented sepsis, reasonable support within the health record must be present for that 
diagnosis.  
 
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 from November 6, 2021, to November 12, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mini Inogen 3 portable oxygen tank. 
 
You asked the Plan to pre-approve a mini Inogen 3 portable oxygen tank. You say that the enrollee needs the 
specific small transportable oxygen. You say that the enrollee is in a day care center, and he has diseases that make it impossible to transport the cylindrical oxygen balls which do not last 8 hours. You say that the 
requested brand and type of oxygen machine is necessary for the enrollee to avoid hospitalization. The Plan 
denied your request. The Plan says the enrollee meets the criteria for a portable oxygen concentrator; however, 
not the brand specific item requested. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 mini Inogen 3 portable oxygen tank. 
Our reviewer says that the criteria for coverage of OON services have not been met. Our physician reviewer 
found the Plan's denial is medically justified on the basis that it is offering adequate care to the meet the 
enrollee's medical needs through referral to a different brand of portable oxygen tank. There is nothing unique 
about the enrollee's condition that would make it medically necessary to use the mini Inogen 3 portable oxygen 
tank. The Plan has shown that they have in-network providers who are able to meet the Standards of Care 
required for treatment of the enrollee's condition. 
 
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 mini Inogen 3 portable oxygen tank have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a mini Inogen 3 portable oxygen tank.
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 you are requesting inpatient rehabilitation for the 
enrollee.  The Plan denied your request. The Plan says rules for IRF care have 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 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: 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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary. 
 
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 the enrollee appears to be unstable but improving with current treatment and requires 
additional short-term acute care services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility.  
 
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.