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

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable gaseous 
oxygen system (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable gaseous oxygen system. You say that 
the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for the requested items have not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 an oxygen concentrator and a portable 
gaseous oxygen system. Our reviewer says that the requested items are not medically reasonable and necessary 
in this case. Our physician reviewer found that you have chronic obstructive pulmonary disease (COPD) and 
have been on oxygen at night in the past. However, clinical notes indicate you have not been using oxygen in 
months. The medical records do not include any recent data that meet criteria for oxygen need. There was a 
single resting saturation of peripheral oxygen (SpO2) value of 88% on a visit in 2018, but a visit on December 
9, 2021, showed SpO2 of 95%.  There is no documented testing during exercise and no testing at night with your obstructive sleep apnea (OSA) 
being adequately treated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator and a portable gaseous oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a 
portable gaseous oxygen system (E0431).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair and commode chair to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the lightweight wheelchair and commode chair from an OON provider. You 
say that the enrollee is a paraplegic and is confined a wheelchair. The Plan denied your request. The Plan says 
the requirements for OON coverage have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items from an OON provider.  
 
 Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair and commode chair 
to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluoroscopy procedure (76000) provided on October 20, 
2021. 
 
You asked the Plan to pay for a fluoroscopy. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the code at 
issue is included in another billed code. 
 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 code 76000 
is a column II code to column I code 72157. 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 a fluoroscopy procedure (76000) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient medical services provided on September 17, 
2021. 
 You asked the Plan to pay for the outpatient medical services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed correctly according to the Outpatient Code Editor. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that when one or more type T 
or S procedures occur on the same day as a line item containing an Evaluation and Management (E&M) code, 
without modifier 25, I/OCE edit 21 will be returned. This edit indicates that a disposition of Return To Provider 
will be entered. 
 
We looked at the file and Medicare rules. In this case, this claim has been billed with code 68761 which is a 
type T procedure that has been billed along with an E&M code. As modifier 25 was not billed with this code, 
this edit is invoked with the Return To Provider disposition. This means the entire claim will not be paid. Based 
on this information, we decided that Medicare rules for coverage of the outpatient medical services have not 
been met. Therefore, we decided that the Plan does not have to pay for the outpatient medical services provided 
on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on October 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99350) provided on October 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not 
obtained prior to the services being rendered. 
 
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 a home visit (99350) provided on October 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging rendered on April 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 77003 is not supported. 
 
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, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 imaging rendered on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service November 12, 2020, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required 
to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment 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 rental charges for the Trilogy 100 home ventilator for date of service November 12, 2020, billed 
with code E0466.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service August 12, 2020, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment 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 rental charges for the Trilogy 100 home ventilator for date of service August 12, 2020, billed with 
code E0466.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the Intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says the requested 
procedure is not widely used and generally accepted for the proposed use as reported in nationally recognized 
peer-reviewed literature. 
 
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 an Intracept procedure. Our reviewer 
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from May 28, 2020, 
through June 26, 2020. 
 You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says there 
are no daily skilled nurse or therapist needs. 
 
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 continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of the 
admission, the enrollee required skilled rehabilitation services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs. As of May 27, 2020 the enrollee did not require any 
skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care as of May 27, 2020. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; 
however, her functional improvement had plateaued by May 27, 2020, and she did not require any further 
inpatient skilled rehabilitation services. The enrollees function was at or near her prior level of function and 
she could be discharged to a lower level of care for further services. As of May 27, 2020 the member required 
custodial services. The denial for further inpatient skilled care is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from May 28, 2020, through  
June 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy to be provided in a hospital setting. 
 
You asked the Plan to pre-approve a colonoscopy to be provided in a hospital setting. You say that the service 
needs to be performed in a hospital. The Plan denied your request. The Plan says it is not medically necessary 
for this service to be performed in a hospital. 
 
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 colonoscopy to be provided in a 
hospital setting. Our reviewer says that the requested colonoscopy to be provided in a hospital setting is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the provide 
documentation indicates a request was made for inpatient services to perform a follow-up screening non-
emergent colonoscopy. As this procedure is typically done in an ambulatory center and as the provided 
documentation does not suggest an expected complication or prolonged aftercare for the enrollee, hospital 
services will be considered not medically necessary for this procedure. 
 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 colonoscopy to be provided in a hospital setting have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a colonoscopy to be provided in a hospital setting.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service January 12, 2021, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required 
to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.   
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment 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 rental charges for the Trilogy 100 home ventilator for date of service January 12, 2021, billed with 
code E0466.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the Magnetic resonance imaging (MRI) spinal canal and contents 
(72148). 
 
You asked the Plan to pre-approve an MRI. You say that please see the attached denial for an MRI and 
corresponding records and consider approving the service. The Plan denied your request. The Plan says that the 
records do not support that the criteria has been met for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has completed a trial of physical therapy without significant relief of symptoms. An MRI is 
the next step. Plain films revealed significant degenerative facet arthrosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
the Magnetic resonance imaging (MRI) spinal canal and contents (72148).  
 
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.