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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the enrollee clearly meets indications for this 
procedure. The Plan denied your request. The Plan says studies have not proven that this service is helpful for 
treatment of the enrollee's condition. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation is lacking regarding findings supporting of the spinal vertebral bodies as being 
the overwhelming primary generators of the enrollee's chronic persistent pain. There is no compelling rationale 
presented or extenuating circumstances noted to support the necessity of this request as an exception to 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Life2000 system is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD). The Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. The evidence supporting safety and 
effectiveness in the treatment of COPD is inadequate. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dry needling (20561, 20560). 
 
You asked the Plan to pre-approve dry needling. You say that you want to appeal this 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 dry needling. Our reviewer says that the 
requested dry needling is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient high quality, long-term evidence in the literature that this procedure is 
effective for your pain condition. Therefore, the reviewer found that the requested services are 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 dry needling have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dry needling (20561, 20560).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93971-26-LT provided on July 20, 2022. 
 
You asked the Plan to pay for procedure code 93971. You say that this service was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says that this service has an MUE of 1, but one unit 
was billed. Therefore, this service was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules 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. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot 
be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, procedure code 93971 has an MUE of 1 and an MAI value of 3. The 
documentation provided shows that one unit of code 93971 has been billed, which means that the MUE has not 
been exceeded in this case. The Plan argues that one unit has been billed, and no documentation or explanation 
has been provided to support that this service was not billed correctly. The Plans denial is not substantiated in 
this case. Therefore, we decided that the Plan has to pay for procedure code 93971-26-LT provided on July 20, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with testosterone cypionate. 
 
You asked the Plan to pre-approve testosterone cypionate. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with testosterone 
cypionate.  
 Benefits for testosterone cypionate 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 15, 2022, to 
August 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 15, 2022, to August 
12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse more for hearing aids provided on July 14, 2022. 
 
You asked the Plan to reimburse more for hearing aids. You say that you called in on June 10, 2022, and were 
told by the Plan representative that your policy has $3,000 reimbursement every 5 years for hearing aids, and 
you had to use a licensed provider. You also say the representative confirmed that your provider was a usable 
provider. The Plan denied your request. The Plan says that Medicare payment is not available. The Plan also 
says that payment was made using the Plan fee schedule, based on location of services. 
 
The Plan must follow Medicare rules. The rules 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. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids up to $3,000 once every 60 months when you see any licensed hearing provider in the United 
States. 
 
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 substantiated how they processed the request for 
reimbursement of hearing aids. The Plan applied a cost-sharing amount that does not match the benefit for 
hearing aids. The Plan did not provide the enrollees original request for reimbursement or receipt of payment. 
The Plan did not provide any evidence that the enrollees $3,000 hearing aid benefit has been exhausted. 
Therefore, we decided that the Plan has to reimburse more for hearing aids provided on July 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services billed with codes 74177 and 71260 for 
September 8, 2022. 
 
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 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 items/services at issue were 
reimbursed by the Plan on October 13, 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services billed with codes 74177 and 71260 for 
September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen therapy. 
 
You asked the Plan to pre-approve home oxygen therapy. You say that the requested home oxygen therapy is a 
medical necessity for you. The Plan denied your request. The Plan says the request is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that 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 home oxygen therapy. Our reviewer 
says that home oxygen therapy is not medically reasonable and necessary in this case. Our physician reviewer 
found that the available records do not contain any oxygenation measurements that indicate a requirement for 
oxygen. A 6-minute walk test in the hospital showed you did not desaturate below 93% during activity 
breathing room air. The pulmonologist's progress note indicates you do not need oxygen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home oxygen therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen therapy.
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 January 25, 2021, to January 31, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our physician 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 in this case, the documentation 
doesnt support the PDPM that was submitted by the skilled nursing facility. There is no indication that the 
beneficiary needed extensive nursing services due to an active infectious disease that required isolation. The 
partial adjustment to PDPM LAQD1 was appropriate. 
 
We looked at this 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 skilled nursing facility (SNF) services provided to the enrollee from January 25, 2021, to January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the procedure was separate from the evaluation 
and management service. The Plan denied your request. The Plan says the code was billed without an 
appropriate modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99284 was billed with a 25 modifier. The medical records do not show that this visit 
was significant and separate from the dislocation treatment, code 23650. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 billed for date of service August 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services you received on June 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the bill needs to 
show what services you had, procedure code(s), diagnosis code(s) and what you paid. 
 
The Plan must follow Medicare rules. The rules 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. The Plan argues that the bill needs to show what services you had, as well as 
procedure code(s), diagnosis code(s) and what you paid. The records do not show that the Plan made efforts to 
obtain records for the services you received. The Plan has not provided a valid denial rationale. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services you received on June 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 19, 2021, 
to November 22, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 metabolic encephalopathy (G93.41). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this service is not supported in the medical record. Our physician reviewer found the 
documentation does not indicate that the diagnostic work-up and treatment ordered by the treating medical 
providers supported a diagnosis code G93.41 (metabolic encephalopathy).  
 
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 on November 19, 2021, to November 22, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (36005, 75820) provided on August 10, 
2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 find that CPT codes 36005 & 75820 are not supported in the medical record. Specifically, these codes are 
inclusive to the primary procedure, code 37328. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (36005, 75820) provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00731) provided on August 29, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says another anesthesia code was already paid for this 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 find that CPT code 00731 is not supported in the medical record. Specifically, anesthesia code 01920 has a 
higher base unit value and was already paid for this date of service. Code 00731 was not billed with a modifier 
to show a separate and distinct service. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (00731) provided on August 29, 2022.