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

 
We decided that the Plan does not have to pre-approve blepharoplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for overturn of this request for surgery cannot be granted. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documented patient complaints do not justify functional surgery. The documentation in the case file 
does not support that the enrollee is experiencing significant interference with vision or superior or lateral 
visual fields, difficulty reading due to superior visual field loss, or looking through the eyelashes or seeing the 
upper eyelid skin. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (99284) provided March 17, 2020. 
 
You asked the Plan to pay for emergency department visit. You say that the records provided should support 
the necessity of the service in dispute. The Plan denied your request. The Plan says bill primary carrier. The 
plan did not receive a primary carrier explanation of benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary to 
the primary Group Health Plan. As the secondary insurer, the Plan cannot be held responsible for emergency 
department visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for emergency department visit for the evaluation and management of a patient 
(99284) provided March 17, 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. 
 
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 care you need can be done at a lower level of care. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and three 
localized deliveries of antimicrobial agents (D4381 x3) provided on August 20, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test and localized deliveries of antimicrobial 
agents. You say that you would like to appeal these services. The Plan denied your request. The Plan says these 
services are not covered under your 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 
adjunctive pre-diagnostic test (D0431) and three localized deliveries of antimicrobial agents (D4381 x3) 
provided on August 20, 2020.  
 
Your complaint about your dissatisfaction with the Plan sending you to this provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 24, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are on a fixed income and you 
cannot afford this. 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 $225 
copayment for outpatient diagnostic tests/diagnostic radiology.  
 
You have been asked to pay a $225 copayment for an MRI. An MRI falls within the outpatient diagnostic 
tests/diagnostic radiology 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 MRI 
provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the medical services provided on August 19, 2020. 
 
You asked the Plan to reimburse for the medical services. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says the provider is out-of-network, the services 
were not referred by a network provider or rendered in a participating facility, and the services were not urgent 
or emergent. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the medical services provided on August 19, 
2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 6, 2020, to 
August 7, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says that the inpatient care was not medically necessary and 
a lower level of care would have been appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented with acute exacerbation of congestive heart failure and had room air O2 
sat of 85%. The enrollee had hypoxemia on room air and imaging evidence of acute pulmonary edema.  It was 
reasonable to expect 2 or more midnights necessary for this patient given hypoxemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 6, 2020, to August 7, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Skilled Nursing Facility (SNF) stay provided from June 26, 
2020, to July 19, 2020. 
 
You asked the Plan to pay for SNF care. You say that you are requesting reimbursement for these charges. The 
Plan denied your request. The Plan says the denial of payment for SNF care is correct. The Plan also says that 
they have approved payment for July 20, 2020, to July 25, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing 
needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a 
skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a Skilled Nursing Facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for a Skilled Nursing Facility (SNF) stay provided from June 26, 2020, to July 19, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 monitor. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this is a case where the product is being paid for out of pocket by the enrollee, and they simply need a 
prescription for this product. The monitor is helping greatly in the medical management of the enrollee. 
 
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 prescription for the monitor have been met. Therefore, we decided that the 
Plan has to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee.  
 
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 a hearing aid examination provided on August 19, 2020. 
 
You asked the Plan to pay for the hearing aid examination. The Plan denied your request. The Plan says you 
must see the Plans hearing provider to use this benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aid examination was not provided by 
the Plans hearing benefit provider. Based on this information, we decided that the Plan's rules for coverage of 
the hearing examination have not been met. Therefore, we decided that the Plan does not have to pay for a 
hearing aid examination provided on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee did not have a Medicare covered transplant. 
 
The Plan must follow Medicare rules. The rules say that immunosuppressive drugs are covered for a Medicare 
covered organ transplant.  
 
We looked the file and Medicare rules. The Plan indicated the enrollee had his transplant in October of 2003 
and did not receive Medicare entitlement until January of 2005. Based on this information, we decided that 
Medicare rules for coverage of Tacrolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tacrolimus for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar orthosis provided on June 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the enrollee has had chronic low back pain for more 
than 12 years. The Plan denied your request. The Plan says the documentation does not support the replacement 
of the brace. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was provided a lumbar orthosis on March 2, 2020. This orthosis serves the 
same purpose as the orthosis at issue in this appeal. The documentation does not show that the current orthosis 
needed to be replaced. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis 
provided on June 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study. 
 
You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because it is 
suspected that the member has sleep apnea. The Plan denied your request. The Plan says there is insufficient 
clinical information to determine if this service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, 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. Based on this information, we decided that Medicare rules for 
coverage of the sleep study have not been met. Specifically, the record does not include any clinical 
information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does 
not have to pre-approve the sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that you believe this is medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
procedure is considered experimental and investigational. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve block for the treatment of pain associated with osteoarthritis is 
considered experimental and investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that you would benefit from a 
short SNF stay to regain strength to safely return home. The Plan denied your request. The Plan says you do 
not require skilled services on a daily basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found from a nursing perspective, the 
beneficiary received oral medications and insulin. The beneficiary had stable vital signs. He was treated for 
congestive heart failure and atrial fibrillation. Regarding rehabilitation services, the beneficiary received PT 
and OT in the acute hospital. The beneficiary was at a contact guard assist level with functional mobility 
including gait to 200 feet with a rolling walker. The beneficiary required varying assist with ADLs. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require daily skilled therapy. This beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 29, 2020 and 
billed under code G0483. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the date of service on the claim does not match the medical records received. The Plan 
made several attempts to have the provider submit additional medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide documentation to support the services 
billed. In this case, there are insufficient records to support the services billed on the date of service reported. 
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 pay for lab services provided to the enrollee on May 29, 
2020 and billed under code G0483.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 14, 2020, to 
July 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient hospital care was medically 
necessary. The Plan denied your request. The Plan says starting on July 17, 2020, inpatient care was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found a note dated 12:59 on July 16, 2020, states the enrollee would be transferred to a 
mental health psychiatric facility pending placement. The enrollee was noted to be stable without acute 
inpatient hospital care needs. The remainder of hospital care did not involve complex treatment or decision 
making. The enrollee maintained stable vital signs for the rest of the stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided July 14, 2020, to July 26, 2020.