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

 
We decided that the Plan does not have to pre-approve the Lipiflow treatment (92499). 
 
You asked the Plan to pre-approve this service. You say that the Lipiflow treatment is medically necessary. The 
Plan denied your request. The Plan says the Lipiflow treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that dry eye syndrome is a chronic condition, for which there is no cure; long-term treatment is required. 
The Lipiflow procedure may be potentially effective for your condition, but remains experimental and 
investigational at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Lipiflow treatment (92499).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 12, 2019. 
 
You asked the Plan to pay for the services provided. You say that the claim was filed timely. The Plan denied 
your request. The Plan says the claim was received past the allowed timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until July 30, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on March 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88360, 88342) provided on April 
1, 2020. 
 
You asked the Plan to pay for laboratory services. You say that these services were billed correctly. The Plan 
denied your request. The Plan says the billing of these codes is not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88305, 88360, 88342 are not supported in the medical record. Specifically, the medical 
record does not support that these services were performed on the billed date of service, April 1, 2020. Based 
on this information, we decided that Medicare rules for coverage of laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services (88305, 88360, 88342) 
provided on April 1, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomograph (SPECT) scan 
(78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the enrollee meets the criteria for coverage. 
The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SPECT acquires information on the concentration of 
radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical conditions 
including but not limited to those listed above.  
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is indicated and medically necessary in this case. Our physician reviewer found the NCD indicates 
that the indications listed above are some for which this service is covered but they are not otherwise an 
exhaustive list. There is utility in the performance of DaT SPECT scans in differentiating between idiopathic 
and drug induced Parkinson's Disease is well supported within current literature. Making the differentiation 
between these diagnoses can also lead to meaningful changes in treatment approaches and strategies. 
 
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 SPECT scan have been met. Therefore, we decided that the Plan has to pre-
approve a single photon emission computed tomograph (SPECT) scan (78803).  
 
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 advanced testing provided on April 23, 2020. 
 
You asked the Plan to pay for the services provided. You say that the testing will guide decision making to 
determine the direction of the treatment plan. The Plan denied your request. The Plan says coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that genomic analysis panel testing is only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee has non-small cell 
lung cancer or metastatic colorectal cancer. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the advanced testing 
provided on April 23, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed place of 
service is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. ER services were not billed on the facility claim. Additionally, the 
imaging report does not corroborate that the order came out of the ED. The documentation submitted does not 
support the use of POS 23 on this claim. 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 provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 14, 2020, 
through May 10, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim was filed timely. The Plan denied 
your request. The Plan says the claim was filed past the allowed twelve month time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient hospital care was not filed until June 18, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from March 14, 2020, through 
May 10, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart 
failure exacerbation and shoulder surgery. The enrollee's medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of a benign lesion. 
 
You asked the Plan to pay for the lesion paring or cutting. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
service 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 11056 is paring or cutting of benign hyperkeratotic lesion 
(e.g., corn or callus); two to four lesions. 
 
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 lesion paring or cutting. Our reviewer says that CPT code 
11056 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include sufficient documentation to validate that a paring or cutting of benign 
hyperkeratotic lesion (e.g., corn or callus); two to four lesions was performed on March 11, 2020. 
 
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 lesion paring or cutting have not been met. Therefore, we decided that the 
Plan does not have to pay for the paring or cutting of a benign lesion.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the cost for the comprehensive evaluation provided on September 21, 
2020. 
 
You asked the Plan to reduce the cost for the comprehensive evaluation. You say that you were charged 50% of 
the cost. You say that the claim should be adjusted to reflect a $40 copayment. The Plan denied your request. 
The Plan says that the 30% coinsurance applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees pay a $40 copayment for each Medicare-covered, out-of-network 
specialist office visit. Covered services include consultation, diagnosis, and treatment by a specialist. 
 
The Plan says you must pay 30% coinsurance for an annual wellness visit. Based on the Plan contract, 
however, you cannot be asked to pay more than a $40 copayment for the comprehensive evaluation. The 
comprehensive evaluation is not considered an annual wellness visit. Therefore, we decided that the Plan has to 
reduce the cost for the comprehensive evaluation provided on September 21, 2020, from $120 to $40.  
 
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 pre-approve additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan has approved a total of 23 physical therapy visits from 
1/1/20 to the present. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and 
it does not appear that the enrollee requires the unique skills of a professional therapist to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee has been authorized an additional session which will allow for review 
of an independent exercise program which she should be competent in at this point. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bedside drainage bag (A4357) provided on September 4, 
2020. 
 
You asked the Plan to pay for the drainage bag. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this supply was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code A4357 is not supported in the record. Specifically, this supply was billed without the 
required modifier. Based on this information, we decided that Medicare rules for coverage of the drainage bag 
have not been met. Therefore, we decided that the Plan does not have to pay for the bedside drainage bag 
(A4357) provided on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130), mandibular 
immediate denture (D5140), 14 simple extractions (D7140 x14), two surgical extractions (D7210 x2), two bone 
replacement grafts for ridge preservation (D7953 x2), and alveoloplasty in conjunction with extractions 
(D7310) provided from July 30, 2020, to August 5, 2020. 
 
You asked the Plan to pay for the maxillary immediate denture, mandibular immediate denture, extractions, 
bone replacement grafts, and alveoloplasty. You say that the extractions were done for medical reasons, and 
you believe they should be covered. You also say that it was necessary for your remaining teeth to be removed 
for fittings of full dentures. The Plan denied your request. The Plan says these services are not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 
maxillary immediate denture (D5130), mandibular immediate denture (D5140), 14 simple extractions (D7140 
x14), two surgical extractions (D7210 x2), two bone replacement grafts for ridge preservation (D7953 x2), and 
alveoloplasty in conjunction with extractions (D7310) provided from July 30, 2020, to August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis provided on July 24, 2020. 
 
You asked the Plan to pay for the lumbar sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says the orthosis is not supported by the referring physician. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked the file and Medicare rules. The Plan has confirmed with the ordering physician listed that he did 
not treat this enrollee or write the order. Based on this information, we decided that Medicare rules for 
coverage of the lumbar sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar sacral orthosis provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lens tinting you were provided on October 16, 
2020. 
 
You asked the Plan to pay for the tinting. The Plan denied your request. The Plan says this is 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 does not cover lens tinting. 
 
We looked at the file and the Plan's rules. While the Plan paid for the eyeglasses, the requested lens tinting is 
not a covered benefit under your plan. Therefore, we decided that the Plan does not have to pay for the eyeglass 
lens tinting you were provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network behavioral health services. 
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says this is not a continuity of care issue and this treatment 
can be provided in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide this treatment. Your provider did not submit medical records that show this would qualify as a 
continuity of care issue. Therefore, we decided that the Plan does not have to pre-approve out of network 
behavioral health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the individual psychotherapy session 
(90837) provided August 31, 2020. 
 
You asked the Plan to waive the copayment for the psychotherapy session. You say that you have never talked 
to the doctor's other than having a virtual session with this provider. The Plan denied your request. The Plan 
says the claim processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $40 
copayment for specialty care physician for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment for specialty care physician for the psychotherapy session. the 
psychotherapy session falls within the Physician/Practitioner services, including doctor's 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 the individual psychotherapy session (90837) 
provided August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the 
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage 
exceeds the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers twelve one-way transportation trips per calendar year when each one-way trip does not 
exceed thirty miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.