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

 
We decided that the Plan does not have to pre-approve a portable oxygen system for the enrollee.  
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical documentation does not establish severe chronic lung disease, or symptoms 
related to oxygen deficiency. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
obstructive sleep apnea, with hypoxemia at night. Positive airway pressure (PAP) titration shows that 
continuous positive airway pressure (CPAP at 12 cm H2O adequately corrects the sleep disordered breathing. 
However, hypoxemia persists. There is no documentation of hypoxemia while awake at rest or with exercise. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
exertional dyspnea. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
with settings that could be delivered by bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) for this member with chronic obstructive pulmonary disease (COPD) is not 
covered. 
 
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 the home ventilator. Our physician 
reviewer found the Life2000 System is not medically necessary. This patient has COPD, requiring 
supplemental oxygen. The Life2000 System is not a true ventilator, because it is not capable of providing full 
ventilatory support. It is intended for use during activity. There are no high-quality clinical trials demonstrating 
that it is effective in the treatment of COPD. Further, this enrollee does not meet criteria for a home ventilator. There is no carbon dioxide (CO2) retention on the arterial blood gas (ABG). The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contrave for the enrollee. 
 
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 medication 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 Contrave for the enrollee.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (G0156) from March 18, 
2022 forward. 
 
You asked the Plan to pre-approve home health aide services. You say that you need these services to continue. 
The Plan denied your request. The Plan says the home health aide services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 health aide services. Our reviewer says that the requested home health aide services are not medically necessary. Our physician reviewer 
found there is no evidence that the enrollee is currently receiving home health skilled services or that associated 
hoe health aide services are necessary to assist in the provision of the home health skilled services.  
Furthermore, even if home health skilled services are ongoing, it is unclear that home health aide services are 
required five times per week, given the documented availability of able and willing caregivers. As such, the 
requested home health aide services are not shown to be medically necessary or coverable. 
 
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 health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services (G0156) from March 18, 2022 forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement of toenails provided on 
February 15, 2021. 
 
You asked the Plan to waive the copayment for toenail debridement. You say that you only had your toenails 
clipped and there was no wound on your foot. You also say that the provider wants you to pay for something 
that was not there on your foot. 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 a $40 
copayment for a specialist visit.  The debridement of toenails (code 11721) is the removal of the toenail bed and tissue. The service was 
provided by a specialist. You have been asked to pay a $40 copayment for toenail debridement. Toenail 
debridement falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 debridement of toenails provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 
81455) provided on August 17, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says this genomic sequence analysis screening panel, CPT 81455, is non-covered by 
Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
This genomic sequence analysis panel, CPT 81455 Targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, is non-
covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as not medically 
necessary and screening testing. Therefore, we decided that the Plan does not have to pay for the targeted 
genomic sequence analysis panel (CPT code 81455) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a telephone medical discussion provided on 
September 20, 2021. 
 
You asked the Plan to waive the copayment for a telephone medical discussion. You say that that a nurse called 
you to give you instructions on a surgery procedure. You also say that you were unaware you would be charged 
$45. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 did not provide medical records to show when then surgery was 
performed. Code 99442 is for a telephone evaluation and management service by a physician or other qualified 
health care professional who may report evaluation and management services provided to an established 
patient, not originating from a related service provided within the previous seven days nor leading to a service 
or procedure within the next 24 hours or soonest available appointment. We are unable to determine if cost 
sharing applies without medical records. Therefore, we decided that the Plan has to waive the copayment for a 
telephone medical discussion provided on September 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission into assisted living facility. 
 
You asked the Plan to pre-approve admission into assisted living facility. You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the 
enrollee does not qualify for an assisted living facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 admission into assisted living facility. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
assisted living care is necessary to meet the enrollees needs and to improve and maintain the participant's 
overall health status. Records document the enrollee is independent with her activities of daily living and 
transfers and can walk greater than household distances independently with a walker. There are no additional 
medical issues noted since the prior denial of assisted living placement on 01/10/2022 other than a diagnosis of 
COVID-19 infection on 02/09/2022 with minimal symptoms that was managed as an outpatient on over-the-
counter medications. The only other additional information provided was a re-request for assisted living 
placement due to personal conflict in the enrollee's home and the fact that another PACE participant was 
accepted into assisted living care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission into assisted living facility have not been met. Therefore, we decided 
that the Plan does not have to pre-approve admission into assisted living facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT) code 0012M) provided on 
September 16, 2021. 
 
 
 
 
 
 
 
 
 
 
 
 You asked the Plan to pay for the laboratory service. You say that the service was medically necessary, and you 
are requesting the Plan cover the service. The Plan denied your request. The Plan says this service is not 
covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. The 
rules say that non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, this 
service is not covered. Therefore, we decided that the Plan does not have to pay for the laboratory service 
(CPT) code 0012M) provided on September 16, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you have documented skilled nursing needs. It is 
unclear whether you are still receiving enteral feeds. You are receiving twice-daily sacral wound care and 
require frequent repositioning. You do not have documented skilled therapy needs. Daily skilled services are 
required to establish a maintenance program or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 imaging services provided to the enrollee on 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 this is bundled into another service billed on the same day by the same provider. 
 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 imaging services provided to the enrollee on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with seat attachment. 
 
You asked the Plan to pre-approve a walker with seat attachment. You say that that you need the walker to be 
able to get in the shower. The Plan denied your request. The Plan says that a second piece of equipment with or 
without additional accessories that is for the same of similar medical purpose as existing equipment is not 
covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as a walker 
with seat attachment. Therefore, we decided that the Plan does not have to pre-approve a walker with seat 
attachment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(CPT code G0453) provided on July 19, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0453 
is a column II code to column I code 95957. 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 the continuous intraoperative neurophysiology monitoring (CPT 
code G0453) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pharmacogenetic testing (CPT code (s): 81220, 
81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, 81355) provided on August 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The enrollee had 
molecular pharmacogenetic testing on August 3, 2021. The denial remains upheld as non-covered as Medicare 
denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code 
must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for molecular 
pharmacogenetic testing (CPT code (s): 81220, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, 
81355) provided on August 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 11, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on September 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and 
S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. 
Therefore, we decided that the Plan does not have to pay for the supplies rendered on September 8, 2021.