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

 
We decided that the Plan does not have to pre-approve oxygen equipment.  
 
You asked the Plan to pre-approve the requested oxygen equipment. You say that the enrollee meets the criteria 
for coverage of oxygen equipment. The Plan denied your request. The Plan says the maximum number of rental 
payments has been paid. No further payment can be made until the RUL of 5 years has elapsed.  
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly payments. 
 
We looked at the file and Medicare rules. The current oxygen equipment was received by the enrollee on 
March 21, 2019. with the 36th payment being made for date of service March 21, 2022. The enrollee will not 
be eligible for new equipment until March 21, 2024, or after, when the RUL ends.  
 Based on this information, we decided that Medicare rules for coverage of the requested oxygen equipment 
have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen equipment.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 for date of service January 5, 2023. 
 
You asked the Plan to pay for procedure code 93005. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 93005 is not payable as billed. Specifically, code 93005 is assigned a Q1 indicator 
(Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator S, T, or 
V"). CPT code 99285 25 was assigned final status indicator V since the APC assigned was 5025. This 
service would not be separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 93005 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93005 for date of service January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift (E1399) provided on July 7, 2023.  
 
You asked the Plan to pay for a stair lift. You say that you would like to remain in your own home as long as 
you can. To do this, you need 2 stair lifts to get from the entrance up to the 2nd level of your home. The Plan 
denied your request. The Plan says the stair lifts are not covered because they are considered convenience items 
that are not primarily medical in nature.  
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift (E1399) provided on July 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient care provided from August 8, 2023, 
through August 14, 2023. 
 
You asked the Plan to pay for the continued inpatient care. You say that the enrollee required the hospital care 
provided.  The Plan denied your request. The Plan says the enrollee was not receiving active treatment beyond 
the last covered day of the stay. 
 
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 pay for the continued inpatient care. Our reviewer 
says that the hospital stay beyond the date in question was not medically necessary. Our physician reviewer 
found the enrollee was found after prolonged failure of self-care and toileting. She was initially evaluated in the 
medical unit prior to transfer to the psychiatric unit. As of the date in question, the enrollee was 
hemodynamically stable tolerating her medical regimen and an oral diet. She required no inpatient diagnostic 
studies or therapeutic interventions. The review has determined that the continued hospital stay beyond August 
7, 2023, was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for the continued inpatient care provided from August 8, 2023, through August 14, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (P9604) provided on April 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 code P9604 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge". 
 
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 use of code P9604 is 
not supported by the records provided. Our reviewer found that the laboratory report includes a collected and tested specimen. However, it does not include documentation to support travel 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the services (P9604) provided on April 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 28, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you have billed the service at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines require the underlying condition to be sequenced first, if applicable, followed by 
the manifestation. Wherever such a combination exists, there is a use additional code note at the etiology 
code, and a code first note at the manifestation code. 
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code T81.40XA, 
defined as Infection following a procedure, unspecified, initial encounter. This diagnosis code belongs to a 
code category with a "use additional code" note. An appropriate manifestation code has not been reported on 
the claim. Based on this information, we decided that Medicare rules for payment of this claim have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on November 
28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on April 26, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for Medicare Part B prescription drugs provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure and manual therapy techniques 
provided on July 06, 2023. 
 
You asked the Plan to pay for therapeutic procedure and manual therapy techniques. You say that this service is 
supported in the records. 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 therapeutic procedure 
and manual therapy techniques provided on July 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic exam (31575) provided on 
August 08, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic exam (31575). You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $245 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay a $245 copayment for the diagnostic exam (31575). This item/service falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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. The allowed amount is lesser than the copayment due, the copayment of $168.12 has been applied 
correctly. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic exam 
(31575) provided on August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is necessary because it will help you 
control your blood sugar through nutrition and diet. The Plan denied your request. The Plan says the Medicare 
coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the CGM is prescribed to help the 
enrollee see impact from foods on their blood sugars. The coverage criteria for a CGM requires insulin use or 
low blood sugars. Although the CGM will likely help this enrollee, the enrollee is not having low blood sugars 
that we are told of nor is the enrollee using insulin so the coverage criteria for a CGM are not met. If additional 
relevant information is available as to why finger stick meter would not suffice for this enrollee or if the 
enrollee is indeed having low blood sugars, it should be submitted and the case re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and Outpatient Intravenous Insulin 
Therapy (OIVIT) services provided on June 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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 code 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter". 
 
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 use of code 99214 is 
not supported by the records provided. Our reviewer found that the provided documentation does not support a 
moderate level of medical decision-making, nor is there a documented duration of this encounter of 30-39 
minutes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. 
 
The rules also say that OIVIT is not reasonable and necessary for any indication. Services comprising an 
Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished 
pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not have to pay for the office visit 
(99214) and Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (P9603) provided on August 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 code P9603 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually traveled". 
 
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 use of code P9603 is not supported by the records provided. Our reviewer found that the laboratory report documents an A1C test 
was performed and results reported, however the documentation does not support travel 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the services (P9603) provided on August 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425-RH (9 units) billed for date of service 
July 17, 2023. 
 
You asked the Plan to pay for procedure code A0425-RH. You say that this service was necessary and should 
be paid. 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 August 2, 2023. Although two claims were submitted with different ambulance 
services billed (A0426, A0428), there is no evidence that ambulance services were provided twice on the same 
date. The line at issue appears to be an exact duplicate of the same line on the other claim. It is unclear if one 
claim was intended as a corrected claim based on the documentation provided. Based on this information, we 
decided that the Medicare rules for procedure code A0425-RH have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code A0425-RH (9 units) billed for date of service July 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99223 and 99239 for date of service July 21, 2023, to 
July 23, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99239. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. This is due to lack of evidence of prior payment. The 
documentation did not show the check/remittance information to show that the services were paid previously. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99223 and 99239 
have been met. Therefore, we decided that the Plan has to pay for procedure codes 99223 and 99239 for date of 
service July 21, 2023, to July 23, 2023.  
 
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 waive the copayment for the insertion of a heart monitor (33285) 
provided on July 11, 2023. 
 
You asked the Plan to waive the copayment for the insertion of a heart monitor (33285). You say that the cost 
share is wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $325 
copayment for Outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $325 copayment for the insertion of a heart monitor (33285). This item/service falls within the Outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers 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 the insertion of a heart 
monitor (33285) provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories (K0861, 
K0108, E2300, E2363, E32311, E2620, E2624, E1012, E0955, E0128, E0953, E1028, E0950 and E1028). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing on that grounds that 
Medicare has reviewed and approved this request. The Plan denied your request. The Plan says the enrollee 
does not have medical need for multiple power options included with K0861 group 3 power wheelchair. As the 
requested Group 3 power wheelchair with multiple power options is not reasonable and necessary, none of the 
requested accessories can be covered.  
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 1. A neurological condition. 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. The record is very unclear about how 
seat elevation will improve access and what limitations exist with the current chair. The enrollee has intact skin 
with current chair which does not include recline. The request is for a replacement and upgrade of current 
chair. The enrollee is reported to have a permobil 3 power wheelchair, which per manufacturer website, does 
not have recline feature.  
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair and accessories (K0861, K0108, E2300, E2363, 
E32311, E2620, E2624, E1012, E0955, E0128, E0953, E1028, E0950 and E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 24, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. 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 a home visit provided on 
April 24, 2023.