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

 
We decided that the Plan does not have to pre-approve a portable home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device will improve the enrollee's 
chance of survival and improve her quality of life. This will also decrease the likelihood of further hospital 
readmissions. It is medically necessary. The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in TTV-VAPS 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 has severe obesity. A 
diagnosis of COPD is mentioned, as well as obesity-hypoventilation syndrome. The enrollee was hospitalized 
in November 2022 for acute congestive heart failure. ABG showed very mild CO2 retention with PaCO2 50, 
which decreased to 47 (normal) on BiPAP. There is no documentation of chronic CO2 retention with ABG 
done while stable as an outpatient. There is no documentation of COPD with pulmonary function tests.  If the 
enrollee does have chronic CO2 retention, she may benefit from BiPAP as an outpatient. If the enrollee has 
severe COPD, AVAPS can be provided via BiPAP. 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 portable home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309), debridement 
(11042), and chemical cautery (17250) provided on August 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care, debridement, and chemical cautery. You say 
that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
not authorized. 
 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 subsequent nursing facility care (99309), 
debridement (11042), and chemical cautery (17250) provided on August 19, 2022, by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) and debridement 
(11043, 11042) provided on August 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care and debridement. You say that you want the 
Plan to pay for the service. The Plan denied your request. The Plan says the services were not authorized. 
   
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 subsequent nursing facility care (99308) and 
debridement (11043, 11042) provided on August 12, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological examination of the chest (71046, Q0092, 
R0070) provided on August 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiological examination of the chest. You say that you want the Plan to pay for 
the service. The Plan denied your request. The Plan says the services were not authorized. 
 
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 radiological examination of the chest (71046, 
Q0092, R0070) provided on August 26, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 5, 2022, 
to April 6, 2022. 
 
  You asked the Plan to pay for acute inpatient hospital care. You say that the denied days were medically 
necessary and appropriate, and you would like this claim to be reviewed and approved for acute inpatient 
reimbursement. The Plan denied your request. The Plan says this request is not medically necessary because 
the records show the enrollee quickly responded to treatment during the observation period and did not have 
severe findings needing additional treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 5, 2022, to April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses and additions provided on August 18, 
2022. 
 
You asked the Plan to pay for the knee orthoses and additions. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed 
supply codes. 
 
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.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records did not contain sufficient documentation of the 
enrollees medical condition to substantiate the necessity for the type and quantity of items ordered and for the 
frequency of use. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses and additions 
provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically III 
(SSBCI) services. 
 
You asked the Plan to pre-approve SSBCI services. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI services have not been met. Specifically, we have confirmed that you do not have a high 
risk for hospitalization. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental 
Benefits for the Chronically III (SSBCI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on April 15, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you do not have any eye diagnoses 
and you do not feel that you should pay the specialist copayment. 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 a $40 
copayment for each Medicare-covered eye exam.  
 
You have been asked to pay a $40 copayment for the eye exam. This item/service falls within the vision 
services benefit category. The medical record shows diagnoses including dry eye syndrome and meibomian 
gland dysfunction which makes the eye exam medical in nature. 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 eye exam provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110 and 97530 billed for date of service 
June 1, 2022, to June 16, 2022. 
 You asked the Plan to pay for procedure codes 97110 and 97530. The Plan denied your request. The Plan says 
payment for code 97110 and 97530 is bundled into payment for code 92526. 
 
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 97110 and 97530 are column II codes to column I code 92526. 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 97110 and 97530 billed for date of service June 1, 2022, to June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that you would be 
charged for the visit and are requesting the bill to be paid by the Plan. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 29, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary. 
 
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 the documentation does not support the medical necessity for admission to an IRF 
due to lack of medical complexity and lack of nursing needs. While the enrollee may need physical therapy 
and/or occupational therapy, their rehabilitation needs can be safely provided in an alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053) provided on 
May 3, 2022. 
 
You asked the Plan to pay for the comprehensive metabolic panel. You say that this service should be covered. 
The Plan denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the comprehensive metabolic panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the comprehensive metabolic panel (80053) provided on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care (99233) provided on September 23, 2021. 
 
You asked the Plan to pay for hospital physician care. You say that you are appealing this denial. The Plan 
denied your request. The Plan says that this code exceeds the maximum number of services allowed for a single 
date of service. 
 
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 denied the use of code 99233 due to exceeding the maximum number 
of services allowed for a single date of service. You billed 1 unit of this code. The Plan did not provide any 
evidence to support that additional units of 99233 were billed or covered for this date of service. Therefore, the 
Plan has not shown that its decision to deny payment for this service is correct or justified. Therefore, we 
decided that the Plan has to pay for subsequent hospital care (99233) provided on September 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CTA, lower extremity, with contrast material(s), 
including noncontrast images, if performed, and image postprocessing (CPT code 73706). 
 
You asked the Plan to pre-approve the CTA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the request is not medically necessary under Medicare because it is not supported 
by clinical evidence. 
 
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 the CTA have been met. Medical 
records were not provided to verify if the testing is necessary according to Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve the CTA, lower extremity, with contrast material(s), 
including noncontrast images, if performed, and image postprocessing (CPT code 73706).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), annual wellness visit (G0439), 
influenza vaccine *90694), and administration (G0008) provided on November 24, 2021. 
 
You asked the Plan to pay for the physician services. You say that your insurance has paid claims previously. 
You say that you nor your doctor's clinic have been notified that this is not covered. You also say that your 
booklet says you can see any doctor that accepts Medicare. The Plan denied your request. The Plan says 
services performed by an immediate family member are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that expenses that constitute charges by immediate 
relatives of the beneficiary or by members of their household are not covered. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Specifically, the plan confirmed that the provider in this 
case is an immediate family member. Therefore, we decided that the Plan does not have to pay for the office 
visit (99214), annual wellness visit (G0439), influenza vaccine *90694), and administration (G0008) provided 
on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) power standing 
feature (E2301) and an attendant control (E2331). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says these items are not 
primarily medical in nature and not covered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the power seat elevation feature (E2300) power standing feature (E2301) and an attendant control 
(E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on August 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on August 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 3, 2022, to May 
25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 3, 2022, to May 25, 
2022.