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

 
We decided that the Plan does not have to pay for the medical services provided on June 27, 2020. 
 
You asked the Plan to pay for the medical services.. You say that you would like this claim to be reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has not been filed in a 
timely manner as required by Medicare rules. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services. was not filed until July 10, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on June 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye exam (92004) and eyeglass frames 
(V2020). 
 
 You asked the Plan to pre-approve a medical eye exam and eyeglass frames. You say that you need glasses for 
daily living to see up close and far. You also say that you received glasses back in March and you cannot see 
with them, you see blurry. You can no longer return the glasses you were given since it's been 3 months 
already. You are requesting new glasses, with a new doctor at a new facility. The Plan denied your request. The 
Plan says you have exhausted your vision benefits for 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says you receive one routine eye exam and a $400 allowance once every calendar 
year. 
 
We looked at the file and the Plan's rules. The records show you exhausted your $400 maximum vision 
allowance as well as an eye exam on March 18, 2022. Based on this information, we decided that the Plan's 
rules for coverage of a medical eye exam and eyeglass frames have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a medical eye exam (92004) and eyeglass frames (V2020).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
January 1, 2022, to January 12, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you were not aware 
that this copayment would be applied to this stay. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
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 $188 per 
day from days 21 to 44 for skilled nursing facility (SNF) care. ($188 x 11 days = $2,068) 
 
You have been asked to pay $$2,068 for a skilled nursing facility stay. A skilled nursing facility stay falls 
within the Skilled Nursing Facility (SNF) Care 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 a skilled nursing facility stay provided from January 1, 2022, to January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are included in the 
dialysis services. 
 
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 lab services provided on January 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from October 
27, 2021, to November 23, 2021. 
 
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 no final claim was submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records do not show that this home health claim was reported correctly. 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 home health services provided to the enrollee from October 27, 2021, to November 23, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional emergency department visit provided to the 
enrollee on February 12, 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 documentation received does not indicate that the enrollee was seen in the emergency 
department twice on this date of service 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 documentation received did not indicate that the enrollee was seen in the emergency department twice on this date of service by the billing 
provider. The review has determined that the records did not support that separate and distinct emergency room 
visits were rendered on this date. 
 
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 an additional emergency department visit provided to the enrollee on February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood vessel repair (35206) provided on March 15, 2022. 
 
You asked the Plan to pay for the blood vessel repair (35206). You say that the medical records should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says procedure code 
35206 is not supported by the medical records submitted. 
 
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 35206 is repair blood vessel, direct; upper extremity. 
 
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 blood vessel repair (35206). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes end to end lymphovenous bypasses. Blood vessel repair is an incorrect code to report 
for the service provided. In this case, services should be reported with a more appropriate procedure code. 
 
  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 blood vessel repair (35206) have not been met. Therefore, we decided that 
the Plan does not have to pay for the blood vessel repair (35206) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine services on March 14, 
2022. 
 
You asked the Plan to waive the copayment for nuclear medicine services. You say that you would like to 
request reconsideration for the cost share on the claim. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $495 
copayment for nuclear medicine services.  
 
You have been asked to pay a $495 copayment for nuclear medicine services. Nuclear medicine services 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 nuclear medicine services on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee is a prime candidate for targeted Botox 
injections. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because the Plan requires a trial of Dysport before it will approve Botox. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Botox. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Dysport. The record does not show that 
this drug would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for negative pressure wound therapy provided to the enrollee on December 
11, 2021. 
 
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 that the documentation provided does not support the use of negative pressure wound therapy. 
 
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 44015: 
 
Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in 
addition to primary procedure) 
 
CPT 44310: 
 
Ileostomy or jejunostomy, non-tube 
 
CPT 97605: 
 
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical 
equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per 
session; total wound(s) surface area less than or equal to 50 square centimeters 
 
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 supported by the medical records. Our reviewer found that the enrollee is status post subtotal 
colectomy (12/11/21) requiring wound care pre and post-operatively. An abdominal wound VAC was placed 
according to the operative note. Negative pressure wound therapy provided to the enrollee on December 11, 
2021 appeared to be found in the records.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
negative pressure wound therapy provided to the enrollee on December 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided on March 29, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the orthotics were medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics provided on March 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 23, 2022. 
 
You asked the Plan to pay for the services provided. You say that the physician provided services based on 
their particular expertise. The Plan denied your request. The Plan says two separate anesthesia services were 
not performed on this date of service. 
 
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 looked at the file and the rules. The claim information provided shows that anesthesia services were billed 
and paid for by the Plan for the enrollees cardioversion procedure. Only one anesthesia code is reported for 
payment purposes. Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on February 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 4, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The genetic testing panel at issue includes the FANCC gene. Panels 
of tests that include this gene are statutorily excluded. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage 
have not been met because the requested service is 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 a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex procedure is indicated to treat skeletally mature patients suffering from pain, 
numbness and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of 
moderate lumbar spinal stenosis. The enrollee has multi-level degenerative disease including severe spinal 
stenosis at L4-L5, the level requested for treatment. The elements of the coverage criteria are not satisfied 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 16, 2022, to February 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were not informed of any 
member responsibility under this plan. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $295 per 
day for days 1-7 and $0 per day after day 7 for each inpatient stay after the deductible is met.  
 
The file shows that you were in the hospital from February 16, 2022, to February 20, 2022, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $295 per day for the first 4 days of 
inpatient care. The total for your stay is $1,180 ($295 copayment x 4 days = $1,180). The inpatient care falls 
within the Inpatient Hospital Care 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 
inpatient hospital care provided from February 16, 2022, to February 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on February 22, 2022. 
 
You asked the Plan to pay for the 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 services at issue were reimbursed 
by the Plan on March 24, 2022. 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 services have not been met. Therefore, we decided 
that the Plan does not have to pay for the services (71045) provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (E1392). 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the records provided do 
not support that the criteria has been met and the request cannot be considered reasonable and necessary. 
 
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 the oxygen concentrator Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has exercise oxygen desaturation to 88% and qualifies for supplemental 
oxygen during activity. However, there is no testing to show that SpO2 can be maintained >91% during 
exercise using an oxygen conserving device and flow rate of 1 to 4 Lpm. A portable oxygen concentrator is not 
medically necessary because Medicare criteria are not met. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator, rental (E1392).