Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to hold you harmless for outpatient therapy services provided from April 12, 
2021, to December 13, 2021. 
 
You asked the Plan to hold you harmless for the outpatient therapy services. You say that these services are not 
being paid and they were medically necessary. The Plan denied your request. The Plan says that it did not 
process your appeal within the required time frames. 
 
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 Plan has provided no information regarding its denial rationale.  
These services were rendered by a network provider, and the Plan has failed to explain why these claims have 
been denied.  The Plan has failed to provide any Notices of Denial it may have issued.  The case narrative the 
Plan supplied in the file submitted does not explain why these claims were denied.  There is some very limited 
documentation in the file that the Plan may have alleged that you "reached your maximum allowed benefit", 
but the Plan has failed to supply any documentation to support that assertion.  The burden is on the Plan to 
prove that its denial is supported, and they have failed to do so in this case. Therefore, we decided that the Plan 
has to hold you harmless for outpatient therapy services provided from April 12, 2021, to December 13, 2021.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from May 28, 2022, to 
June 3, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the patient had terminated hospice 
prior to this hospitalization. The Plan denied your request. The Plan says Original Medicare is responsible for 
this bill. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 13, 2022. The inpatient stay in question began before 
the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital services 
provided from May 28, 2022, to June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month (A4595) 
provided July 10, 2022. 
 You asked the Plan to pay for Electrical stimulator supplies. You say that  The Plan denied your request. The 
Plan says evidence of misrepresentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the 
documentation submitted does not include a valid signature from the persons responsible for the care of the 
beneficiary. The Plan made outreach to the ordering provider listed on the claim and confirmed that the 
provider does not know this enrollee. Therefore, we decided that the Plan does not have to pay for electrical 
stimulator supplies, 2 lead, per month (A4595) provided July 10, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) and abdominal x-ray (74018) 
provided on February 19, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the services should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
(71045) and abdominal x-ray (74018) provided on February 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen (E1390). 
 
You asked the Plan to pre-approve the home oxygen. You say that the home oxygen concentrator is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 home oxygen Our reviewer says 
that the home oxygen is not medically necessary. Our physician reviewer found that the medical records do not 
show oxygenation measures that establish a need for supplemental oxygen.  There are no SpO2 readings below 
92% breathing room air as an outpatient. Complete results of overnight oximetry were not provided in the 
records. 
 
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 home oxygen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home oxygen (E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 21, 2021 billed with 
codes 81225, 81230, 81238, 81240, 81241, 81291, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 21, 2021 billed with codes 81225, 81230, 81238, 81240, 81241, 81291, and 81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous CPAP device, an oxygen 
concentrator, and a portable gaseous oxygen system provided on May 5, 2022, to July 5, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you are appealing and 
requesting a reconsideration for the monthly DME cost-share charges. 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 18% 
coinsurance for in-network durable medical equipment.  
 
 
 
 
 You have been asked to pay a total of $59.34 for the CPAP device, oxygen concentrator, and portable gaseous 
oxygen system from May 5, 2022, to July 5, 2022. 
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
18% 
COINSURANCE 
May 5, 2022 E0431 $17.29 $3.11 
May 5, 2022 E1390 $77.63 $13.97 
June 5, 2022 E0431 $17.29 $3.11 
June 5, 2022 E1390 $77.63 $13.97 
June 13, 2022 E0601 $44.99 $8.10 
July 5, 2022 E0431 $77.63 $13.97 
July 5, 2022 E1390 $17.29 $3.11 
TOTAL   $59.34 
 
The items/services fall 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 a CPAP device, an oxygen concentrator, and a portable 
gaseous oxygen system provided on May 5, 2022, to July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD), although there are no pulmonary 
function test results. The enrollee was recently hospitalized with COPD exacerbation and arterial blood gases 
(ABGs) were consistent with severe acute on chronic hypercarbic respiratory failure. The enrollee likely has 
chronic Carbon Dioxide (CO2) retention and may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that the requested Actemra is medically necessary. The 
Plan denied your request. The Plan says the requested Actemra is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Actemra. Our reviewer says that the 
requested Actemra is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of BK viremia in the setting of immunosuppressed state for kidney transplant 
management. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. 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 Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. 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 power mobility devices are covered when specific 
criteria are met. 
 
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 scooter. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the documentation does not 
support that you are unable to accomplish mobility self-care tasks in the home. Additionally, there is no 
documentation to support that you intend to use the scooter in the home or that there has been an evaluation of 
the home to assure the scooter would fit. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pay for a CGM and supplies. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM and supplies. Our reviewer says that 
the requested CGM and supplies are not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not have diabetes mellitus. The enrollee is not insulin treated with three 
or more daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump.  
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (CGM) and supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 1, 2021, to November 30, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 that there were no identifiable skilled nursing or skilled therapy service needs. The 
enrollee not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pay for skilled nursing facility (SNF) services provided to the enrollee from November 1, 2021, to 
November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 20, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the lab services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services provided to a SNF inpatient 
under Part A are billed by the SNF, not the laboratory, due to consolidated billing for SNFs. 
 
We looked at the file and Medicare rules. Separate Part B payment cannot be made for this lab testing. The lab 
services are covered under Part A and included in the facility payment. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on July 20, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. 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. 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 FreeStyle Libre CGM have been met. 
Specifically, medical records were requested but not received. Medical necessity cannot be established without 
this documentation. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 
continuous glucose monitor (CGM).
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, and the enrollee's needs can be 
met at the current facility. 
 
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 record indicates that the enrollee has ongoing medical issues and still requires 
acute care services. The enrollee continues to receive acute care services, and these have not been denied.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prolia injection rendered on May 13, 2022. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must accept the Medicare allowed 
charge amount as payment in full for their practitioner services. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required charge 
amount. The Plan has requested a corrected claim from the provider. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the Prolia injection rendered on May 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; 30 minutes or less 
(99239) provided on January 19, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services the enrollee 
received were not related to their hospice diagnosis. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management; 30 minutes or less 
(99239) provided on January 19, 2022.