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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not reimbursable in conjunction with any other oxygen codes. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found a portable 
oxygen concentrator is considered not medically necessary because coverage criteria are not met. The records 
show an order for a stationary and portable oxygen concentrator, with an oxygen saturation of 88%. But, there 
are no medical records confirming this, and showing the circumstances under which it was measured. There is 
no documentation of hypoxemia during activity, and no documentation that hypoxemia is corrected using an 
oxygen conserving device with flow rates of 1-4 L/min. There is no documentation of why a portable 
concentrator is needed rather than standard portable tanks. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
24, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service September 24, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641) provided on August 12, 2021. 
 
You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
 
 We asked our coder 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 the breast ultrasound. Our reviewer says that CPT code 
76641 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure 
report does not include documentation of examination of all four quadrants of the breast and retroareolar 
region. Therefore, a complete examination in this case cannot be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan 
does not have to pay for the breast ultrasound (76641) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized foot and advanced knee (L5973, L5828, 
L5830, L5845, L5848, and L5856). 
 
You asked the Plan to pre-approve a computerized foot and advanced knee. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the type of knee for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 computerized foot and advanced 
knee. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
requested Linx system exceeds the enrollee's medical needs and is not medically necessary per LCD L33787 
and the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. 
 
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 computerized foot and advanced knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized foot and advanced knee (L5973, L5828, 
L5830, L5845, L5848, and L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on August 24, 2021. 
 
You asked the Plan to pay for the services provided at 24-hour facility, in addition to basic service (99053). 
You say that the claim was denied stating the level of service was not supported. You say that the patient was 
in need of care which is illustrated by the medical records. The Plan denied your request. The Plan says 
procedure code 99285 has been overturned and CPT code 99053 remains denied as bundled services are not 
eligible for separate payment. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services provided at 24-hour facility, in 
addition to basic service (99053) have not been met. Therefore, we decided that the Plan does not have to pay 
for services provided at 24-hour facility, in addition to basic service (99053) provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement indicating that these services would be included in the dialysis payment. The 
Plan denied your request. The Plan says laboratory services related to the treatment of ESRD are the 
responsibility of the patients dialysis center, even if the tests are not directly related to dialysis. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that records do not show the enrollee requires daily nursing or daily therapy 
services on an inpatient basis. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom abutment (D6057) and implant supported crown 
(D6059) provided on December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are aware that your dental coverage does 
not include certain dental procedures. You also say that you feel this problem was not a cosmetic issue. The 
Plan denied your request. The Plan says the custom abutment and implant supported crown are not listed as 
covered services. 
 
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 custom abutment and implant 
supported crown are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the custom abutment (D6057) and implant supported crown (D6059) provided on December 8, 
2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing and/or 
skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation 
services at a lower level of care. Although further rehabilitation services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing facility. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay the copayments for the imaging services, the physical therapy 
visits, and the surgical services provided from July 26, 2021, to October 8, 2021. 
  You asked the Plan to pay the copayments for the imaging services, the physical therapy visits, and the surgical 
services. You say that you were never told about the copayments until you received a bill and would like the 
Plan to pay for the copayments. The Plan denied your request. The Plan says the proper copayments were 
applied for the services that were rendered. 
 
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 CT Scan, a $40 copayment for each Medicare-covered physical and speech therapy service, and 
a $400 copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.  
 
On September 30, 2021, the copayment amount for the imaging services was $250. From August 9, 2021, to 
October 8, 2021, there was a total of 13 physical therapy visits with the total copayment amount of $520 ($40 
copayment per visit x 13 visits). On July 26, 2021, the copayment amount for the surgical services was $400. 
 
You have been asked to pay a $250 copayment for the imaging services, a $520 copayment for the physical 
therapy visits, and a $400 copayment for the surgical services. The imaging services falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The physical therapy visits falls within 
the Outpatient rehabilitation services benefit category. The surgical services falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 pay the copayments for the imaging services, the physical therapy visits, and the 
surgical services provided from July 26, 2021, to October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on December 23, 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 73565 is not separately payable. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 73565 (bilateral 
knee x-ray, standing, anteroposterior) and 73562 (knee x-ray, three views). Code 73565 is a column II code 
with a modifier indicator of 0 when billed with column I code 73562. No separate payment is made for code 
73565. 
 Therefore, we decided that the Plan does not have to pay for the knee x-ray rendered on December 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on December 10, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered ass 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 Ambulance services.  
 
 
  You have been asked to pay a $182.69 copayment for ambulance transportation services, which is less than the 
standard $250. 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 ambulance transportation services provided 
on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (Hereditary Assessment for Cardiac 
Conditions) provided to the enrollee on September 15, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this denial is appropriate given the clinical scenario. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that Medicare does not cover screening cardiovascular risk assessment testing 
for asymptomatic patients. The requested test was not medically necessary or reasonable. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (Hereditary Assessment for Cardiac Conditions) provided to the enrollee on 
September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 16, 
2021. 
 
You asked the Plan to pay for procedure code 99291. You say that the medical records support payment of this 
claim. The Plan denied your request. The Plan says the records do not support the code billed. 
 
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 99291 is evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the medical record. Specifically, this is a timed code, 
meaning that the minutes spent providing critical care services to the patient must be documented in the 
medical record.  The medical record lists a start time of the critical care visit but does not list an end time.  
Further, the medical record is blank on the last page where you note the following: Total critical care time __ minutes."  Based on this information, we decided that Medicare rules for coverage of procedure code 99291 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed 
for date of service May 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specially sized or constructed and justification 
wheelchair. 
 
You asked the Plan to pre-approve a specially sized or constructed and justification wheelchair. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 specially sized or constructed and 
justification wheelchair. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found while the enrollee may benefit from a 
power wheelchair the requested specially sized/constructed wheelchair exceeds the enrollee's medical need per 
the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) and is not 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 a specially sized or constructed and justification wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a specially sized or constructed and 
justification wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient service visits provided from 
March 24, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayment for the outpatient service 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 $75 
copayment for Outpatient hospital services.  
 
  
You have been asked to pay a $225 copayment for 3 outpatient service visits ($75 x 3 = $225). 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 outpatient service visits provided from March 24, 2021, to 
September 24, 2021.