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

We decided that the Plan does not have to pre-approve revision of upper lip with tissue rearrangement. 
 
You asked the Plan to pre-approve revision of upper lip with tissue rearrangement. You say that you believe 
that all the necessary information was not provided at the time of the initial review and you request 
reconsideration on covering this procedure. The Plan denied your request. The Plan says this request is a 
cosmetic and reconstructive service and is not considered 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 revision of upper lip with tissue 
rearrangement. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee was referred to a plastic surgeon for 
evaluation of the wound. Per the plastic surgeon, there is no functional deficit. The scar is misaligned, and was 
not repaired properly. There is no documented functional deficit for which revision of the upper lip 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 revision of upper lip with tissue rearrangement have not been met. Therefore, 
we decided that the Plan does not have to pre-approve revision of upper lip with tissue rearrangement.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided from May 26, 2020, through June 10, 
2020. 
 
You asked the Plan to pay for the medical services. You say that the services were provided by a nurse 
practitioner who is legally allowed to bill for services rendered. The Plan denied your request. The Plan says 
that the claim was billed with a registered nurse taxonomy, so the claim processing edit was correctly invoked, 
and another claim needs to be submitted. 
 
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 has not provided a valid denial rationale in this case. Although the 
taxonomy reported on the claim corresponds to a registered nurse, the taxonomy is not a required field for 
claim processing. The reported National Provider Identification (NPI) number correctly lists the primary 
taxonomy of the provider at issue as nurse practitioner. A nurse practitioner is a Medicare-eligible provider. 
Based on the information provided, the denial based on this being an ineligible provider has not been 
substantiated. Therefore, we decided that the Plan has to pay for the medical services provided from May 26, 
2020, through June 10, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on October 30, 2018. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says a reimbursement 
request must be made within 12 months (365 days) of the date of service. The Plan says that the completed 
claim was received more than 12 months from the date of service. 
 
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 dental services was not filed until April 10, 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 limited oral evaluation (D0140) and periapical x-ray (D0220) provided on 
October 30, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT guidance services coded 77014. 
 
You asked the Plan to pre-approve the CT guidance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 77014 
for the CT guidance services has a bundled relationship with code 77470. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CT guidance services coded 77014.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012) provided on February 19, 2020. 
 
You asked the Plan to pay for an eye exam. You say that the service should be covered. The Plan denied your 
request. The Plan says there is a $10 copayment for a routine eye exam every year. 
 
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 these services once a year with a $10 copayment. 
 
We looked at the file and the Plan's rules. You received an eye exam. Based on this information, we decided 
that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does 
not have to pay for an eye exam (92012) provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on June 16, 2020 
 
You asked the Plan to waive the copayment for specialist services. You say that you have had this before and 
didn't have a copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $40 
copayment for physician/practitioner services/specialty care.  
 
You have been asked to pay a $40 copayment for specialist services. The correct copayment has been applied 
to the services that were provided. Specialist services fall within the physician/practitioner services/specialty 
care 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 specialist services provided by a 
participating provider on June 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says any chiropractic service that is not manual manipulation for the treatment of subluxation 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the only treatment 
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. The submitted imaging studies of the cervical spine, dated 
July 7, 2020 reveal cervical spondylosis and degenerative changes, minimal anterolisthesis at C5-6 and mild 
anterolisthesis at C7-T1 and the thoracic spine reveals mild spondylosis. These findings do not reveal evidence 
of a subluxation. The submitted chart notes/office visit notes from May 1, 2020 through October 22, 2020, 
some 22 chiropractic visits/treatments reveal lumbar, pelvis, sacrum and cervical asymmetry/misalignment 
identified on a sectional or segmental level with hypomobile vertebral subluxations noted, pain/tenderness, 
range of motion abnormality/deficiency by visual assessment and tissue, tone changes by way of muscle 
spasms in the characteristics of contiguous of associated soft tissue to digital palpation. An examination dated 
June 25, 2020 reveals, mainly, tenderness and muscle spasms/hypertonicity of the lumbar spine, with trigger 
points and stated subluxations of L4, L5. The sacroiliac joints reveal tenderness to palpation, muscle tension 
and hypertonicity, trigger points and stated subluxations of the pelvis, sacroiliac joint and the sacrum. The 
cervical spine reveals tenderness to palpation, muscle spasm and hypertonicity, trigger points and stated 
subluxation in the cervical spine. These findings do not reveal evidence of subluxation per Medicare 
guidelines. Thus, no chiropractic treatments are either supported or allowed per Medicare guidelines.
 
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-approve chiropractic services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the swallowing function x-ray rendered on June 8, 2020. 
 
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 is a duplicate. 
 
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. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. There is no documentation that the services were 
performed more than once. 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 swallowing 
function x-ray rendered on June 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex extremity study rendered on 
June 26, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment 
amount. The Plan denied your request. The Plan says the copayment was applied 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 $125 
copayment for each Medicare-covered diagnostic service, not including x-rays, performed in a physician's 
office or at a free-standing facility.  
 
Review of the file shows that you received a duplex extremity study on June 26, 2020. You have been asked to 
pay a $125 copayment for these services. These services fall within the Medicare-covered diagnostic service, 
not including x-rays, performed in a physician's office or at a free-standing facility 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 duplex extremity study rendered on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on February 18, 2020. 
 
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says non-
emergent services received by an out-of-network provider are not covered by the Plan. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
chiropractic treatment. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for chiropractic treatment provided on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiogram. 
 
You asked the Plan to pre-approve transthoracic echocardiogram. You say that you are appealing the plan's 
denial. The Plan denied your request. The Plan says the request for the transthoracic echocardiogram 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 transthoracic echocardiogram. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found The review indicates that the enrollee has a history of aortic stenosis, HTN, 
HLD, CKD Stage III, and carotid stenosis. Her provider has requested a transthoracic echocardiogram. Per the 
documentation she has no symptoms of chest pain, shortness of breath or syncope. Physical exam reveals a 3/6 
systolic murmur. The review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiogram have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transthoracic echocardiogram.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided from January 31, 
2020 to February 3, 2020. 
 
You asked the Plan to waive the copayment for inpatient care. You say that this should be fully covered. The 
Plan denied your request. The Plan says this processed 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 $395 
copayment for each day for days 1 to 4 of Medicare-covered hospital care.  
 
You have been asked to pay a $1,185 copayment for inpatient care ($395 copayment per day x 3 days = 
$1,185). 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 inpatient care provided from January 31, 2020 
to February 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $219.50 charged for ambulance transport provided on 
April 3, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says you are actually being charged less than the normal 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 $250 
copayment for ambulance transport. You have been asked to pay less than the normal copayment for this 
service. 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 $219.50 charged for ambulance transport 
provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Autologous Platelet Rich Plasma Eye Drops, 20%. 
 
You asked the Plan to pre-approve Autologous Platelet Rich Plasma Eye Drops. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item 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 Autologous Platelet Rich Plasma Eye 
Drops. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have a diagnosis of unspecified blepharitis of the 
right and left eyes and the upper and lower eyelids, with severe dry eyes, surface staining, and debilitating light 
sensitivity. Autologous Platelet Rich Plasma Eye Drops are not considered medically reasonable and necessary 
for the treatment of blepharitis of the eyelids, dry eyes, surface staining, and/or light sensitivity. Therefore, you 
do not meet criteria for the requested eye drops. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Autologous Platelet Rich Plasma Eye Drops have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Autologous Platelet Rich Plasma Eye Drops, 20%.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on July 24, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you had to go to the ER 
because you were not getting the help you needed at the urgent care center. The Plan denied your request. The 
Plan says the correct copayment has been applied. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit 
took place, the correct copayment has been applied. An emergency room visit falls within the emergency care 
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 an emergency room visit 
provided by a participating provider on July 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient care you received. 
 
You asked the Plan to pay for the inpatient care. You say that you were afraid you had the virus and this should 
be covered. The Plan denied your request. The Plan says that inpatient care was not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the inpatient services by a contract provider. The file does not show that the Plan provided 
notice that the inpatient care would not be covered. Under Medicare rules, this means the inpatient care is 
considered approved by the Plan. Additionally, medical records were not submitted by the contract provider to 
support the Plan?s denial. Therefore, we decided that the Plan has to pay for the inpatient care you received.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care and debridement services 
provided on October 24, 2019 by an OON provider. 
 
You asked the Plan to pay for the initial nursing facility care and debridement services. You say that these 
services were necessary. The Plan denied your request. The Plan says the provider of service is a non-
participating provider, and the enrollee does not have OON benefits. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 initial nursing facility care and debridement 
services provided on October 24, 2019 by an OON provider.