Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services 
for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Clinical documentation 
shows that patient is medically complex and will continue to require close physician oversight of multiple 
active comorbidities/medical complications. Evaluating therapists (physical and occupational therapy) both 
recommend intense therapy thus IRF criteria has been met and is medically necessary. Our physician reviewer 
found that the enrollee's condition meets Medicare criteria for IRF 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  
 
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 the Inogen One G4 portable oxygen concentrator, 
battery pack and cart. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this brand is not covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. 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 item Our reviewer says that the 
requested item is not medically reasonable or necessary. Our physician reviewer found that you have chronic 
obstructive pulmonary disease (COPD) and have reportedly been provided with a stationary oxygen 
concentrator and portable tanks. According to your letter, you owned your own portable oxygen concentrator, 
but it became inoperable and could not be repaired. There is no documentation in the medical record why 
portable tanks will not meet your needs. There is no documentation that SpO2 during exercise can be 
maintained more than 91% using an oxygen conserving device at 1 to 4 L/min. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Inogen One G4 portable oxygen concentrator, battery pack and cart.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (L5781). 
 
You asked the Plan to pre-approve a vacuum assisted socket system. You say that the primary function of the 
vacuum pump is to suspend the prosthetic limb. This device is a complete device that is an addition to a lower 
limb prosthesis and defined by Medicare. You disagree with the denial. The Plan denied your request. The Plan 
says the use of vacuum pumps for residual limb volume management and moisture evacuation systems among 
amputees is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. 
Experimental and investigational items are not covered by Medicare. 
 
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 vacuum assisted socket system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found per documentation; the physician note indicates a recommendation for an 
elevated vacuum system. The literature reviewed indicates that further research is needed with clinical trials 
that recruit larger sample sizes and report long-term outcome data for the requested vacuum suspension system. 
 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 vacuum assisted socket system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a vacuum assisted socket system (L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36200 and 77001 billed for date of service 
October 1, 2021. 
 
You asked the Plan to pay for procedure codes 36200 and 77001. You say that you have provided 
documentation to support payment. The Plan denied your request. The Plan says payment for codes 36200 and 
77001 is bundled into payment for codes 36240 and 36200. 
 
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 codes 
36200 and 77001 are column II code to column I codes 36240 and 36200. This claim has not been billed with 
an appropriate modifier to bypass the edit. 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 codes 36200 and 77001 billed 
for date of service October 1, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 16 additional physical therapy sessions provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these sessions are medically necessary. The 
Plan denied your request. The Plan says that additional physical therapy visits are not medically necessary. 
 
`The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that these services are medically necessary. Our physician reviewer found clinical documentation shows that 
not all therapy goals, which appear to be reasonable, have been met and the enrollee has bilateral shoulder 
impingement thus 16 additional physical therapy sessions would be 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 physical therapy have been met. Therefore, we decided that the Plan has to pre-
approve 16 additional physical therapy sessions provided by a participating provider. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eight acupuncture visits provided from 
December 1, 2020 to February 10, 2021. 
 
You asked the Plan to waive the copayment for the acupuncture visits. 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 $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $774.64 copayment for 8 acupuncture visits, which is less than the standard $250 
each. Acupuncture services fall within the Outpatient hospital services 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 eight acupuncture visits provided from December 1, 2020 to 
February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee was hospitalized in 
August with hypoxemic and hypercarbic respiratory failure. The ABG at that time was consistent with acute 
CO2 retention, but CO2 retention persisted over the next couple of days. A diagnosis of COPD exacerbation 
was made, but there are no pulmonary function tests to confirm, and the enrollee has no history of smoking or 
prior COPD.  There is no ABG done as an outpatient while stable to confirm chronic CO2 retention. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. If chronic CO2 retention is confirmed, the 
enrollee may benefit from BiPAP during sleep. 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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the laparoscopy, surgical, with 
radical hysterectomy (58548) provided on March 23, 2022. 
 
You asked the Plan to reimburse an additional amount for the surgical service. You say that you went to the 
doctor that was closes to your home. You say that the doctor did not notify you that they were not a participant. 
You also say that you were not advised you needed prior authorization. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
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.  
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service 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. Therefore, we decided that the Plan does not have to reimburse an additional 
amount for the laparoscopy, surgical, with radical hysterectomy (58548) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory pathogen panel testing provided on December 22, 
2021. 
 
You asked the Plan to pay for respiratory pathogen panel testing. You say that respiratory pathogen panel 
testing was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
have 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 looked at the file and Medicare rules. In this case, the record shows that the enrollee was provided with 
respiratory pathogen panel testing for greater than 5 respiratory pathogens. Based on this information, we 
decided that Medicare rules for coverage of respiratory pathogen panel testing have not been met. Therefore, 
we decided that the Plan does not have to pay for respiratory pathogen panel testing provided on December 22, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on November 24, 2021, 
November 29, 2021, and December 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapy services. You say that there is no prior authorization required for the 
services you provide, and you would like the claim to be fully paid. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the therapy services provided on November 24, 
2021, November 29, 2021, and December 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that this is medically necessary. The 
Plan denied your request. The Plan says that use of a portable ventilator to deliver ventilatory support via 
settings that could be equally provided by a BiPAP with AVAPS settings is inconsistent with Medicare rules. 
 
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 mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically reasonable and necessary. You have a 
diagnosis of severe COPD. It appears from the records that a home ventilator was prescribed about a year ago 
after a hospitalization for acute respiratory failure with CO2 retention, and you have been using it. Those 
details are not provided. The ventilator is being used in a mode that can be provided via BiPAP, with AVAPS. There is no evidence that this has been tried and failed as an outpatient. Medicare does not cover a home 
ventilator when used as BiPAP. Our physician reviewer found that your condition does not meet Medicare 
criteria for a home mechanical ventilator. 
 
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 mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service December 
16, 2021. 
 
You asked the Plan to pay for procedure code 99024. You say that this code should not be bundled. The Plan 
denied your request. The Plan says procedure code 99024 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 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve swingaway, retractable, or removable hardware 
(E1028), a custom fabricated wheelchair back cushion (E2617), and a custom fabricated wheelchair seat 
cushion (E2609). 
 
You asked the Plan to pre-approve swingaway, retractable, or removable hardware (E1028), a custom 
fabricated wheelchair back cushion (E2617), and a custom fabricated wheelchair seat cushion (E2609). You say that the requested swingaway, retractable, or removable hardware (E1028), custom fabricated wheelchair 
back cushion (E2617), and custom fabricated wheelchair seat cushion (E2609) are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested swingaway, 
retractable, or removable hardware (E1028), custom fabricated wheelchair back cushion (E2617), and custom 
fabricated wheelchair seat cushion (E2609). 
 
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 swingaway, retractable, or removable 
hardware (E1028), a custom fabricated wheelchair back cushion (E2617), and a custom fabricated wheelchair 
seat cushion (E2609). Our reviewer says that the enrollee does not meet criteria for the requested swingaway, 
retractable, or removable hardware (E1028), custom fabricated wheelchair back cushion (E2617), and custom 
fabricated wheelchair seat cushion (E2609). Our physician reviewer found the requested swingaway, 
retractable, or removable hardware (E1028) is not medically necessary per Medicare rules as the enrollee is 
unable to transfer and needs a Hoyer lift for transfers. The documentation does not indicate this enrollee can 
perform a slide transfer to a chair or bed. The custom fabricated wheelchair back cushion (E2617), and custom 
fabricated wheelchair seat cushion (E2609) are not medically necessary per Medicare rules as the 
documentation does not support why a prefabricated cushion cannot be used for the enrollee's condition over a 
custom fabricated cushion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of swingaway, retractable, or removable hardware (E1028), a custom fabricated 
wheelchair back cushion (E2617), and a custom fabricated wheelchair seat cushion (E2609) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve swingaway, retractable, or removable 
hardware (E1028), a custom fabricated wheelchair back cushion (E2617), and a custom fabricated wheelchair 
seat cushion (E2609).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology visit provided on April 25, 
2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that this copayment was waived in the 
past. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $25 
copayment for each specialist office visit.  
 
You have been asked to pay $25 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a cardiology visit provided on April 25, 2022.