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

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the rechargeable tanks are too bulky 
and heavy to carry around and the limited oxygen provided by those tanks are not enough for you when you are 
out. The Plan denied your request. The Plan says there is no indication the enrollee's current oxygen equipment 
is not meeting their medical need and the enrollee is currently privately paying for oxygen to be delivered to an 
out of area address. 
 
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 equipment 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 chronic obstructive pulmonary disease and asthma and is on 
continuous supplemental oxygen. The enrollee is requesting a portable oxygen concentrator. However, there is 
no documentation that the enrollee is able to maintain oxygen saturation (SpO2) greater than 91% during 
activity using an oxygen conserving device at a flow rate of 1 to 4 liters per minute.  This is a Medicare 
requirement. 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 equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95822, 95927) provided on 
January 12, 2022. 
 
You asked the Plan to pay for the neuromonitoring services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 95822 & 95927 is electroencephalogram (EEG) 
recording in coma or sleep only and short-latency somatosensory evoked potential study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system, in the trunk or head. 
 
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 neuromonitoring services. Our reviewer says that the 
records do not support the codes billed. Our reviewer found there is no documentation in the technical report of 
an electroencephalogram (EEG) recording in coma or sleep only as required for code 95822. There is no 
documentation in the technical report to support code 95927.  
 
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 neuromonitoring services have not been met. Therefore, we decided that the 
Plan does not have to pay for neuromonitoring services (95822, 95927) provided on January 12, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says that repeat administration of this drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that Zilretta 
is medically necessary. Our physician reviewer found this drug is FDA approved for the patient's condition. 
Nothing in the Medicare approved compendia or on the label precludes repeat use of this drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 13101 and 13102 rendered on September 
28, 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 Current Procedural Terminology (CPT) code 13101 and 13102 remain not supported. 
 
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 13101: 
 
Repair, complex, trunk; 2.6 cm to 7.5 cm 
 
CPT 13102: 
 
Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 13101, the 
procedure report does not include sufficient documentation to confirm complex closure. The report documents 
"Findings: difficult closure after wide undermining." In terms of CPT 13102, this procedure is an add on code, 
which requires a primary procedure code. In this case, the primary procedure code cannot be verified, therefore 
this procedure would not be covered. 
 
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 procedure codes 13101 and 13102 rendered on September 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says your benefit for SNF care has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 6, 2023, to May 
16, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 6, 2022, to 
January 27, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
Q codes. 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 pay for the home health services rendered from 
January 6, 2022, to January 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 13, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting this claim be 
reprocessed. The Plan denied your request. The Plan says on this date of service the record indicates the patient 
was in an inpatient hospital status.  
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. 
 
We looked at the file and Medicare rules. The referring claim for this inpatient facility shows admit date of 
October 10, 2022 and discharge date October 15, 2022. Based on this information, we decided that Medicare 
rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided on October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 18, 2022, billed with code 
77001-26-59. 
 You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
the primary procedure. 
 
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 77001 is a column II code to column I code 71275; however, 77001 
was billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that procedure code 77001 would be 
included in the primary Computed tomography procedure, and modifier -59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on July 18, 2022, billed with code 77001-26-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on June 16, 2022. 
 You asked the Plan to pay for the cytopathology services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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. 
 
The cytopathology services at issue in this appeal were requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the cytopathology services provided on June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently unable to walk and need the 
inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's nursing, medical 
management and rehabilitation needs do not require an interdisciplinary team approach to delivery of 
rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93308 billed for date of service September 
22, 2022. 
 You asked the Plan to pay for procedure code 93308. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93308 is bundled into payment for code 93306. 
 
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 93308 
is a column II code to column I code 93306. 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 93308 billed for date of service September 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on January 5, 2023.  
You asked the Plan to pay for the refraction. You say that you believe the refraction should be paid because it 
should be a covered service. The Plan denied your request. The Plan says the service was not a covered benefit. 
 
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 covers this service when received as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not provided during a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on January 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing, ambulance service, conventional air services, 
transport, one way (A0431) and rotary wing air mileage, per statute mile (A0436) provided August 8, 2022. 
 
You asked the Plan to pay for the emergency air ambulance services. You say that based on the clinical 
information documented during transport, you believe this transport meets medical necessity guidelines. The 
Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 find that CPT codes A0431 and A0436 is not supported in the medical record. Specifically, the 
claim was billed with a GZ modifier. Claim lines with GZ modifier are automatically denied as non-covered 
services. The GZ modifier identifies that an item or service is expected to be denied as not reasonable and necessary, and that no advance notice of non-coverage was supplied to the enrollee. If you bill for services 
using the GZ modifier, the claim will go to provider liability and you may not bill the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the emergency air ambulance services have not 
been met. Therefore, we decided that the Plan does not have to pay for rotary wing, ambulance service, 
conventional air services, transport, one way (A0431) and rotary wing air mileage, per statute mile (A0436) 
provided August 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Byooviz. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left eye exudative age-
related macular degeneration with active choroidal neovascularization. He has not tried and failed the Plan's 
required drug, Avastin. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Byooviz is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Byooviz.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the provided records do not support the services 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, the CPT Code Manual definition of code 99223 is: Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 procedure code 99223. Our reviewer says that procedure 
code 99223 does not meet criteria for payment. Our reviewer found that the provided records support a 
comprehensive exam but not a comprehensive history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service October 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia Solution prefilled syringes. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Prolia Solution prefilled 
syringes.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. The Plan denied your request. The Plan says that the 
repairs to the enrollees current wheelchair will cost more than a replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the excess. 
 
The record shows the cost to repair the current wheelchair will cost more than a replacement wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.