Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the cost share for the inpatient hospital stay provided from November 8, 
2022, to November 11, 2022, to the in-network benefit level. 
 
You asked the Plan to reduce the cost share for the inpatient hospital stay. You say that this should have been 
coded as in-network. The Plan denied your request. The Plan says that this provider is out-of-network and you 
have been charged the correct cost share 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 documentation indicating if/when your condition 
stabilized or if your post-stabilization care was authorized. Without this documentation we are unable to 
determine if the out-of-network cost share was applied correctly. Therefore, we decided that the Plan has to 
reduce the cost share for the inpatient hospital stay provided from November 8, 2022, to November 11, 2022, 
to the in-network benefit level.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 8, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service October 16, 
2022. 
 You asked the Plan to pay for procedure code 12002. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 12002 is bundled into payment for code 25650. 
 
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 12002 
is a column II code to column I code 25650. 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 12002 billed for date of service October 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on January 
9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 30, 2022. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
(E0601), humidifier (E0652), and face mask (A7030). 
 
You asked the Plan to pre-approve the CPAP device, humidifier, and face mask. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a claim for an E0601 is submitted and all of the 
criteria have not been met, it will be denied as not reasonable and necessary. A heated (E0562) humidifier and 
face mask is covered when ordered by the treating practitioner for use with a covered PAP (E0470 or E0601) 
device. 
 
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 CPAP device, humidifier, and face 
mask. Our reviewer says that the member does not need this item. Our physician reviewer found this patient 
had attended polysomnography in 2018 that showed mild obstructive sleep apnea, with an AHI of 6.6. It is 
unclear from the records whether the sleep apnea was treated at that time. The Epworth sleepiness score was 
normal at 6 at that time, and there was no history of hypertension, ischemic heart disease, stroke, impaired 
cognition, or mood disorders. The records include a clinical visit on February 9, 2023, that does not provide a 
detailed sleep history, sleepiness score, or a detailed upper airway examination. The patient does have a 
diagnosis of COPD, with an FEV1 of 35% of predicted. CPAP was ordered at a pressure of 5, although there is 
no CPAP titration. In the absence of significant OSA symptoms or other risk factors, Medicare does not cover 
CPAP unless the AHI is greater than 15.   
 
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 CPAP device, humidifier, and face mask have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
(E0601), humidifier (E0652), and face mask (A7030).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
2, 2023. 
 You asked the Plan to pre-approve SNF care after June 2, 2023. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
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 after June 2, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines.  Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
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 after June 2, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
provided on December 6, 2022. 
 
You asked the Plan to pay for the CGM. You say that the enrollee has fluctuating sugar levels that require 
routine mobile glucose monitoring one or more times a day to properly control and manage their diabetes. You also say that the enrollee struggles with pricking their skin to draw blood to test their glucose in any setting. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) and supplies provided on December 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of bilateral extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of bilateral extracranial arteries. You say that this is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage. 
 
The Plan follows Medicare rules.  
 
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 duplex scan of bilateral extracranial 
arteries. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of any neurologic symptoms to warrant the study. 
 
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 duplex scan of bilateral extracranial arteries have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a duplex scan of bilateral extracranial arteries (93880).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the home health care services provided from April 4, 
2022, to May 18, 2022. 
 
You asked the Plan to waive the cost share for the home health care services. You say that your wife was 
trained to administer the drugs. The Plan denied your request. The Plan says that the cost sharing was applied 
correctly. 
 
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 the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to confirm the cost sharing was applied correctly. Therefore, we decided that the 
Plan has to waive the cost share for the home health care services provided from April 4, 2022, to May 18, 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9131 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code S9131. You say that this should be paid for. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9131 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9131 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9131 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9131 billed for date of service November 15, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 29824 and 29826 rendered on June 1, 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 that the 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 
the denied codes is: 
 
CPT 29824: 
 
Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 
 
CPT 29826: 
 
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with 
coracoacromial ligament (ie, arch) release, when performed (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 supported by the medical records. Our reviewer found that in terms of CPT 29824 being 
supported, the  procedure details cite an acromioplasty was performed from anterolateral to posteromedial 
taking off approximately 4mm. The distal clavicle was then coplaned for a distance of 1cm. The records also 
support CPT 29826, as the procedure details cite an acromioplasty was performed from anterolateral to 
posteromedial taking off approximately 4mm. The distal clavicle was then coplaned for a distance of 1cm. This 
was prior to the decision to complete the rotator cuff repair as a mini-open procedure. After this was decided, 
the acromion was cleared of tissue and an additional acromioplasty was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 29824 and 29826 rendered on June 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership provided from January 1, 2023, to 
April 12, 2023. 
 
You asked the Plan to pay for the gym membership. You say that you did not use your Flex Card to cover your 
fitness expenses. You say due to your hip replacement you need to go to aquatic therapy. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only with an allowance for the purchase of plan approved over-the-counter items, health and wellness herbal 
catalog items, and qualifying fitness expenses. 
 
 The Plans rules for coverage of gym benefits have not been met because Specifically, how the benefit is 
administered had changed and you are not eligible for the 2023 reimbursement check. Therefore, we decided 
that the Plan does not have to pay for the gym membership provided from January 1, 2023, to April 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 03, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on January 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that the requested walk-in bathtub is medically 
necessary due to your knee replacement and hip surgery. You also say that you can barely move around. The 
Plan denied your request. The Plan says a walk-in bathtub does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug coded J3490 for date of service January 
6, 2023. 
 
You asked the Plan to pay for the unclassified drug. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this is included in the global surgical package. 
 
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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgical period of surgery procedure 64483. This claim was not billed with an appropriate modifier. This 
code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the unclassified drug have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drug coded J3490 for date of service January 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94729 rendered on October 13, 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 this is an add-on code. 
 
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 94729 is an add-on code and has not been billed with an appropriate primary procedure code. 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 94729 rendered on October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; 4 or more views rendered on 
January 6, 2023. 
 
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 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 71048 is "Radiologic examination, chest; 4 or more 
views." 
 
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 there is a single report of a one 
view chest x-ray on January 6, 2023. In that report, there is a recommendation to consider a four view rib series 
for evaluation. However, there is no report for this recommended four view series in the records submitted. 
 
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 radiologic examination, chest; 4 or more views rendered on January 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Movantik. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Movantik.   
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.