Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88360) provided on March 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, the code billed has a 
professional component / technical component of 1. The service was billed in a facility setting (place of service 
22). The service was not separately billed by the physician with a 26 modifier. 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 lab services (88360) provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage for a portable ventilator (E0466).
You asked the Plan to pre-approve continued coverage for a portable ventilator. You say that the requested device is medically necessary. The Plan denied your request. The Plan says that the requested device does not meet criteria.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a portable ventilator. Our Medical Director states the Products currently classified as HCPCS code E0466, when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in the LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in the policy will be denied as not reasonable and necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued coverage for a portable 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 continued coverage for a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage for a portable ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 & 99053 provided on August 2, 
2022. 
 
You asked the Plan to pay for procedure codes 99285 & 99053. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are 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 CPT code. 
 
We find that CPT codes 99285 & 99053 are not supported in the medical record. Specifically, another 
evaluation and management code was billed by the same billing group on the same date of service (99284). Code 99053 has a status indicator "B" and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99285 & 99053 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99285 & 99053 provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested portable oxygen 
concentrator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a portable oxygen concentrator. 
 
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 a portable oxygen concentrator. Our 
reviewer says that the enrollee does not meet criteria for a portable oxygen concentrator. Our physician 
reviewer found the portable oxygen concentrator is not medically necessary. This enrollee has chronic 
obstructive pulmonary disease (COPD).  Oxygen was prescribed, apparently for activity only. However, she 
lives in a travel trailer and there is no room for a stationary concentrator to use to refill portable tanks. 
However, there is no testing to document that SpO2 is 88% or less with exercise, and that SpO2 can be 
maintained greater than 91% during exercise using an oxygen conserving device at flow 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 a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimental/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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for services provided on July 1, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code was appropriate for the date 
of service. The Plan denied your request. The Plan says the diagnosis code is mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 76882 is ultrasound, limited, joint or other nonvascular 
extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue 
structure[s], or soft-tissue mass[es]), real-time with image documentation. We find that CPT code 76882 was billed with diagnosis code R10.30, unspecified lower abdominal pain. There 
is a more appropriate diagnosis code that specifies the which side the procedure was performed on. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 76882 billed for services provided 
on July 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 19, 2022, to 
May 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from April 19, 2022, to May 4, 2022.
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 you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for SNF care is correct. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service January 18, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that the correct place 
of service was indicated on the claim. The Plan denied your request. The Plan says the codes were not billed 
with the correct modifier.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the outpatient hospital and are not separately payable to the 
independent laboratory. 
 
The records indicate that the specimen was taken while the enrollee was a hospital outpatient. Per the Physician 
Fee Schedule, CPT codes 88341, 88342, 88360, and 88381 have a Professional/Technical indicator of 1. This 
means that CPT codes 88341, 88342, 88360, and 88381 have both a professional and technical component. In 
this case, CPT codes 88341, 88342, 88360, and 88381 has not been billed with an appropriate modifier to 
indicate the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service January 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified oral surgery procedure (D7999), and 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265). 
 
You asked the Plan to pre-approve unspecified oral surgery procedure (D7999), and biologic materials to aid in 
soft and osseous tissue regeneration, per site (D4265). You say that you have called the Plan several times, and 
they have given you different reasons for why they do not cover the services. The Plan denied your request. 
The Plan says this is not a covered benefit under patient policy. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
unspecified oral surgery procedure (D7999), and biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral 
complete series x-ray (D0210) provided on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was never disclosed to you, nor did you sign 
anything, that says any past services would be included in this new 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 July 23, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral 
complete series x-ray (D0210) provided on August 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service March 16, 
2022, to March 18, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service March 16, 2022, to March 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 3, 2022, to 
March 8, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. We find that the home health services are not supported as billed. 
Specifically, the number of days billed exceeds the 30 days for a single period of care. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided from February 3, 
2022, to March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology care with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve neurology care. You say that the requested provider has the highest 
capability for further testing and treatment, and other providers do not have the expertise to explore the option 
of deep brain stimulation for your condition. The Plan denied your request. The Plan says this provider is out-
of-network with the Plan and you can be treated by an in-network tertiary level provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
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 neurology care. Our reviewer says that 
you do not meet Medicare criteria for treatment with the requested out-of-network provider. Our physician 
reviewer found the Plan is directing you to a tertiary medical center to address your needs. Considerations of 
your condition, such as information treatment decisions about deep brain stimulation, are common in tertiary 
academic centers. There is nothing unique about your condition that would make it medically necessary for you 
to see the requested out-of-network provider. The Plan has in-network providers that meet the standards of care 
for treatment of your 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 neurology care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neurology care with an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 2, 2022, to May 31, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that certain data elements are required on the claim and NOA. 
Any claim with incomplete, missing, or invalid information for all of these elements may be returned as 
unprocessable. 
 
Review of the file shows that the claim for these services have a date of service May 2, 2022, to May 31, 2022. 
An NOA was submitted for the period of care; however, the final home health claim does not have a matching 
admission date of January 2, 2022. As the NOA has invalid information, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for the home health services provided May 2, 
2022, to May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by an out-of-network provider on August 1, 2022. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you needed these services. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided by an out-of-network provider on August 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from October 28, 2021, to 
November 5, 2021. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 17, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the inpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for the inpatient services provided from October 28, 
2021, to November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the portable oxygen concentrator provided on January 12, 2022.

You asked the Plan to provide additional reimbursement for the portable oxygen concentrator. You say that you should be reimbursed more. The Plan denied your request. The Plan says that the coinsurance applied is correct.

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 portable oxygen concentrator have not been met. Specifically, the record indicates that the Plan has paid the Medicare allowed amount for this service less the applicable coinsurance. 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 provide additional reimbursement for the portable oxygen concentrator provided on January 12, 2022.