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

 
We decided that the Plan does not have to waive the deductible for continuous positive airway pressure (CPAP) 
on June 14, 2022. 
 
You asked the Plan to waive the deductible for CPAP. You say that you thought you met your deductible 
already and would like your claim reviewed and reprocessed with only a $45 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. Your 
contract with the Plan says that there is a $550 deductible which applies to Durable medical equipment (DME) 
and related supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the Durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $550 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time CPAP was received on 
June 14, 2022. Therefore, we decided that the Plan does not have to waive the deductible for continuous 
positive airway pressure (CPAP) on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 28, 2021, to January 4, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9 and secondary 
diagnosis code J96.01. 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 services at issue in this case were not supported by the medical records. Our physician reviewer 
found that a total bilirubin level was not noted in the record. Repeat arterial blood gas was not noted on 
transfer.  There was no documented platelet count less than 150,000. There were no total bilirubin levels or 
documentation of hyperbilirubinemia noted in the record. There was no documentation of additional GCS 
scores noted in the record. The patient's mental status was documented as "alert and oriented x3", " mental 
status noted as WFL", and "oriented x4" per the record. There was no documented creatinine level 1.2 mg/dL 
or greater and no documented urine output less than 500 mL/day, no acute oliguria or anuria noted in the 
record. The review has determined that the records did not support the use of principal diagnosis code A41.9. 
The records did not support the use of secondary diagnosis code J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 28, 2021, to January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in this way 
and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. Based 
on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation because you cannot walk and 
your stage four pressure heel ulcer needs observation and therapy. You say you live alone and have no support. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be 
met at a lower level of care such as a skilled nursing facility (SNF), home with home health services or home 
with outpatient therapy. 
 
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 you were admitted for pressure ulcers of both heels after a recent stroke. Your 
medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR.) 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee has an internal loop recorder which is 
nearing end of life. You say that it needs to be replaced for management of atrial fibrillation to see if the 
enrollee is in need of medication. The Plan denied your request. The Plan says the requested device is not 
reasonable and necessary in this case. 
 
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 ILR. Our reviewer says that an ILR 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
has a history of atrial fibrillation. There is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an ILR. There is insufficient documentation to 
support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR.)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 20, 2022, to April 26, 2022 and May 10, 2022 to May 19, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says no daily skilled services were needed. 
 
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 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 that based on the medical records provided there is no documentation that the patient 
required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a 
skilled professional nurse or qualified therapist were not required to safely and effectively provide medically 
necessary and reasonable treatment from 04/20/2022 through 04/26/2022 and 05/10/2022 through 05/19/2022. 
The records did not document the need for intravenous medications, new tube feeding, or ostomy care or daily 
complex wound care or respiratory care during this time period. Daily skilled services were not required, as the 
enrollee had reached her maximum potential with rehabilitation and was discharged from skilled services on 
04/19/2022. This patient did not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the nursing facility appear custodial in this case. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from April 20, 2022, to April 26, 
2022 and May 10, 2022 to May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical laminectomy services (procedure code 63047, 
63048) provided to the enrollee on February 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 the denied codes is: 
 
CPT 63047: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
 
 CPT 63048: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes a 
laminotomy (hemilaminectomy) with decompression. In this case there is a more appropriate code to report for 
service provided. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical laminectomy services (procedure code 63047, 63048) provided to the enrollee on 
February 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022, to June 1, 2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2022, to June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on June 
17, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. 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 $350 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. 
 
 You have been asked to pay a $350 copayment for CT scan. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and 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 
copayment for computed tomography (CT) scan on June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this 
copayment, it will cause a financial hardship. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $275 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $275 for these 
services. 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 ambulance services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than Intensity-modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on April 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on April 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on June 27, 
2022, by an OON provider. 
 
You asked the Plan to pay for principal care management services. You say that the providers rely on facility 
staff to verify eligibility and obtain authorization from the patient's insurance company. The Plan denied your 
request. The Plan says the out-of-network 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 principal care management services provided on 
June 27, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reprocess at the in-network rate the cataract surgery provided on 
September 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to reprocess at the in-network rate the cataract surgery. You say that you were not aware 
that the provider you saw was OON. The Plan denied your request. The Plan says although services rendered 
by an OON provider will be covered, they will have a 50% coinsurance. 
 
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 at the in-network rate 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 at the in-network rate these 
items/services. Therefore, we decided that the Plan does not have to reprocess at the in-network rate the 
cataract surgery provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 10, 2022, to May 9, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 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 that based on the medical records provided, there is no documentation that the 
enrollee required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment 
of a qualified therapist or skilled professional nurse were not required to safely and effectively provide 
medically necessary and reasonable treatment from 04/10/2022 through 05/09/2022. Daily skilled services 
were not required (or provided) during this time period. This patient did not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from April 10, 2022, to May 9, 2022.