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. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there must be documentation of an oxygen saturation at or below 
88% taken during exercise or at or above 89% during the day while at rest. 
 
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 these services Our reviewer says that a 
portable oxygen concentrator is not medically reasonable and necessary. You have chronic obstructive 
pulmonary disease (COPD), but are not currently on home supplemental oxygen, and the medical records do 
not show any oxygenation data that meets Medicare criteria for oxygen need. The lowest SpO2 is 90% 
breathing room air at rest. There are no oxygenation measurements during activity or during sleep. Our 
physician reviewer found that your condition does not meet criteria for coverage of a portable oxygen 
concentrator. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a portable oxygen concentrator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 1, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to 
pay this copayment. 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 a $75 
copayment for in-network emergency care.  
 
You have been asked to pay the allowed amount of $72.51 which is less than the $75 copayment for an 
emergency room visit. An emergency room visit falls within the In-Network Emergency 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 an emergency room visit provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331). 
 
You asked the Plan to pre-approve treatment of root canal obstruction. You say that you would like this 
covered. The Plan denied your request. The Plan says that coverage criteria is not met. 
 
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. The Plan covers treatment of 
root canal obstruction only if your age is between zero (0) and twenty (20).  
 
We looked at the file and Plan rules. The file indicates your age is not between zero (0) and twenty (20). Based 
on this information, we decided that the Plan's rules for coverage of treatment of root canal obstruction have 
not been met. Therefore, we decided that the Plan does not have to pre-approve treatment of root canal 
obstruction (D3331).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve atrial fibrillation ablation and supraventricular 
tachycardia (SVT) ablation. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no evidence of any rhythm other than premature 
ventricular contractions requiring ablation at this time. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Based on current 
guidelines as well as the records provided catheter ablation of atrial fibrillation and SVT are not considered to 
be medically necessary for you. Our physician reviewer found that your condition does not meet criteria for 
coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve atrial fibrillation ablation and supraventricular tachycardia (SVT) ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 14, 
2022. 
 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 March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this service is available by a provider in your network. 
 
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/services. Therefore, we decided that the Plan does not have to pre-approve 
knee arthroplasty to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 13, 2021 billed with 
codes 81206, 81292 and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 13, 2021 billed with codes 81206, 81292 and 81301.
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 
October 27, 2021, to October 28, 2021. 
 
You asked the Plan to pay for the services. You say that A41.9 is a valid diagnosis for this encounter, as it was 
demonstrated by the provider, and meets coding guidelines for the principal diagnosis. The Plan denied your request. The Plan says A41.9 is a valid diagnosis for this encounter, as it was demonstrated by the provider, and 
meets coding guidelines for the principal diagnosis. 
 
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.   
 
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 the 
records do not support the use of A41.9 in this case. The appropriate DRG is DRG 193: SIMPLE 
PNEUMONIA AND PLEURISY WITH MCC. While it is acknowledged that the records include a physician-
documented diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were 
present along with an elevated lactic acid, the clinical findings in the record do not sufficiently support the 
diagnosis of sepsis based on Sepsis 3 criteria.  
 
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 October 27, 2021, to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient bilateral L3/4 and L4/5 decompression to be 
provided by an out-of-network (OON) provider for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no network deficiency for these services. 
 
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/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient bilateral L3/4 and L4/5 decompression to be provided by an out-of-network (OON) provider for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the 
enrollee's Medicare Part B benefit for the requested use. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 13, 2020, to December 15, 2020. 
 
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 DRG was updated in this case.  
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 DRG 682 (RENAL FAILURE WITH MCC). 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 in 
this case, the hospital record does not document the presence of oliguria. The range of serum creatinine levels 
documented during the current hospital stay, from 1.62mg/dL to 1.23mg/dL to 1.36mg/dL, does not support 
reporting the diagnosis code for acute kidney failure for this patient with reported underlying renal disease, 
prior findings of an elevated serum creatinine level, and suspicion of chronicity. The serum creatinine levels 
documented, after a period of initial hydration, from 1.23mg/dL to 1.36mg/dL, are consistent with underlying 
chronic kidney disease, rather than with acute kidney failure. The diagnosis code for unspecified acute kidney 
injury is not supported by the hospital record. The review has determined that the records did not support the 
use of diagnosis code N17.9. DRG 071: NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC is 
the appropriate DRG.  
 
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 13, 2020, to December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on November 
22, 2021. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that the authorization was obtained 
from the facility and was added to the date of service. You say that the claim should be reviewed and 
reprocessed. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a 
hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on November 22, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the lower extremity (Mako 
robotic-assisted knee arthroplasty) for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that clearly, providing this type of surgical treatment with 
the use of pre-operative imaging and the robotic system for this patient is better treatment option than a knee 
replacement procedure without the assistance of the robot. The Plan denied your request. The Plan says that the 
documentation does not show that the criteria is met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that if MAKO robotic 
assisted total knee replacement is the procedure to be done on this patient the requested CT scan is a necessary 
part of the procedure for the operative planning and not for diagnosis. This is per the protocol suggested by the 
manufacturer. Thus, if this is the type of procedure to be done for this patient the requested CT will be 
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 the scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the lower extremity (Mako robotic-assisted knee arthroplasty) for the 
enrollee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary, as there is a lot of back 
pain. The Plan denied your request. The Plan says the enrollee has not undergone six weeks of provider-
directed treatment that failed to resolve back pain. 
 
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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that duration of the 
sciatica has not been described. The physical exam does not reveal a neurological deficit. No red flag is noted 
to mandate immediate MRI without a six week trial of physical therapy. Also, a plain x-ray services of the 
lumbar spine has not yet been done. Absent these points, medical necessity of the requested MRI has not been 
established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (BIS). 
 
You asked the Plan to pre-approve Bioimpedance spectroscopy (BIS). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 Bioimpedance spectroscopy (BIS). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had breast cancer treated with surgery and axillary dissection 
and has undergone radiation therapy. You, the enrollee's provider indicates that you are ordering this test to 
"monitor" for lymphedema. However, the submitted records do not document a current diagnosis of 
lymphedema, nor treatment for lymphedema using compression, decongestive massage, nor any other standard 
of care management strategies for lymphedema. Therefore, the enrollee does not meet criteria for the requested 
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 Bioimpedance spectroscopy (BIS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Bioimpedance spectroscopy (BIS).