Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseventeen (17) skilled nursing visits.You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 services. Our physician reviewer found the records do not showthat skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your conditionorto establish/perform a maintenance program to maintain your condition and/or prevent deterioration. You have had extensive skilled nursing (SN) and education on your wound. Caregivers are trained in wound care which is not complex. The wounds are chronic in nature. Additional SN services are not 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 the services have not been met.Therefore, we decided that the Plan does not have to pre-approveseventeen (17) skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery you had at the hospital. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were admitted to the 
hospital, so you shouldn't have an outpatient copayment. The Plan denied your request. The Plan says you were 
not admitted to the hospital as an inpatient- you were in observation status.  The Plan has waived the 
observation copayment, but the Plan says you are still responsible for the outpatient surgery copayment. 
 
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 $300 
copayment for surgery provided in an outpatient hospital.  
 
You have been asked to pay a $300 copayment for the outpatient surgery. Records show that you were not 
admitted to the hospital as an inpatient.  Rather, you were 
admitted to observation, which is considered an outpatient status. 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 outpatient surgery you had at the hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have disease that is causing your foot to be 
in severe pain and you state that you have had lasers and surgeries and everything and nothing seems to work. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy services provided on April 8, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the nasal endoscopy services. You say that you thought there was a prior 
authorization on file. The Plan denied your request. The Plan says this provider is not a network provider and 
you had no authorization to see this provider on this date of service. The only authorization that was granted for 
this provider was effective from October 14, 2019, through April 14, 2020.  The services in question in this 
appeal were rendered prior to this authorization period. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the nasal endoscopy services provided on April 8, 2019 by an out 
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain in your foot. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid surgery (blepharoplasty). 
 
You asked the Plan to pre-approve these services. You say that you have severe headaches and your eyes water 
and burn. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria 
are met. 
 
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 submitted records do not contain 
vision-related symptoms in your medical history. The submitted photographs demonstrate normal marginal 
reflex distance (MRD). The criteria for coverage are not met and the requested blepharoplasty is not reasonable 
or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve upper eyelid surgery (blepharoplasty).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There 
are no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is necessary to improve the enrollee's 
breathing capabilities. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are covered for treatment of 
neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. 
 
We looked at the file and Medicare rules. The record does not indicate that the enrollee has a neuromuscular 
disease or thoracic restrictive disease. While the enrollee is noted to have chronic obstructive pulmonary 
disease, there is no documentation of chronic respiratory failure. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered for the above indiciations. 
 
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 RFA. Our reviewer says that the 
requested RFA is medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that RFA is expected to last more than 6 months, which it did in this case. The pain has returned in the 
same pattern as before. The requested procedure is medically reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve 
repeat radiofrequency ablation (RFA).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting the 
additional routine transportation trips to see your doctor for urgent medical visits. The Plan denied your 
request. The Plan says you currently have ten (10) trips remaining and you will have exceeded your benefit 
limit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips 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. The 25th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 24 additional 
routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the foot (73718) 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says the MRI of the foot is not medically 
necessary because the approved MRI will cover the same area of the body. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
diagram of the region of discomfort provided by the requesting clinician shows the areas of tenderness include 
the lateral malleolus and the midfoot or proximal first metatarsal. Our physician reviewer found a separate MRI 
of the left foot is not indicated as the areas of concern will be evaluated with the approved MRI of the left 
ankle. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the foot (73718)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (64484 and 
64483). 
 
You asked the Plan to pre-approve the transforaminal epidural steroid injections. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says this 
service 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 the transforaminal epidural steroid 
injections. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is ligamentum flavum thickening and disc bulges but 
no frank herniation or significant spinal stenosis. 
 
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 transforaminal epidural steroid injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (64484 and 
64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. Our 
physician reviewer found based on review of the medical records, the enrollee with debility from a multiple but 
stable medical conditions, does not meet the CMS coverage criteria for an IRF admission based on lack of 
medical intensity and nursing needs. There is no evidence of medical issues that require monitoring by an 
inpatient rehab physician three (3) times a week. The documentation does not support that there is a need for an 
intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. This enrollee, 
does not meet the CMS coverage criteria for an IRF admission. The enrollee's rehab needs can be met in an 
alternate, less intense setting such as in an SNF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a revision of total hip arthroplasty (27143) provided on November 4, 
2019. 
 
You asked the Plan to pay for the revision. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the information submitted by the provider does not 
corroborate 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 27134 is revision of total hip arthroplasty; both components, with or without autograft or allograft.  
 
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 revision. Our reviewers says that CPT code 27143 meets 
criteria for billing and reimbursement consideration. Our reviewer found the operative documents CPT 27134.  
"The ceramic on ceramic liner from the initial operation was removed.  There was noted to be backside metal 
wear of the ceramic on ceramic metal-backed liner on acetabulum.  The acetabulum was thoroughly irrigated 
and debrided.  There was excellent compression of the acetabular components, and therefore, a dual mobility 
metal liner was implanted and a dual mobility head was placed onto the proximal body of a restoration modular 
stem".  Therefore this code is 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 the revision have been met. Therefore, we decided that the Plan has to pay for a 
revision of total hip arthroplasty (27143) provided on November 4, 2019.  
 
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: Favorable

 
We decided that the Plan has to pay for Tumor Biomarker Analysis Genetic Testing provided to the enrollee on 
May 17, 2020. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
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 pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has advanced metastatic carcinoma, and is seeking further cancer treatment. The enrollee's 
hematologist documents that a recent PET scan shows recurrence, and that the NGS biomarker testing would 
be used to guide systemic therapy. There is no documentation to suggest that the enrollee has previously been 
tested with the same test using NGS for the same cancer genetic content. 
 
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 testing have been met. Therefore, we decided that the Plan has to pay for 
Tumor Biomarker Analysis Genetic Testing provided to the enrollee on May 17, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift rendered on November 10, 2019. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims lines billed with codes without a KX, GA or 
GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required KX 
modifier. 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 patient lift rendered on November 
10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglass frames (V2020) provided April 3, 2020.You asked the Plan to pay forthe eyeglass frames. You say that the frames should be covered.The Plan denied your request. The Plan says your benefit for eyeglass frames was exhausted at the time the service was provided.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 up to $300 for eyeglasses (frames and lenses)every two years.We looked at the file and the Plan's rules. You received eyeglass frames on July 26, 2018. You were not eligible for new frames as of April 3, 2020. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames have not been met.Therefore, we decided that the Plan does not have to pay foreyeglass frames (V2020) provided April 3, 2020.