Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014) provided on September 20, 
2022. 
 
You asked the Plan to pay for an eye examination (92014). You say that the eye examination visit for was for 
Sjogrens syndrome disease, which is the medical reason for the eye problems. You also say the reason for an 
out-of-network visit, was because of the doctor not agreeing to use this Plan, due to coverage reasons. The Plan denied your request. The Plan says because the provider is out-of-network with the members plan, and 
because there is no coverage when services are rendered by a non-participating provider, the Plan will maintain 
its initial determination to not pay for the submitted claim. 
 
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 when services are received in network. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from coverage. The record shows that services were received by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of an eye examination 
(92014) have not been met. Therefore, we decided that the Plan does not have to pay for an eye examination 
(92014) provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 had network providers 
available who could have provided 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 an office visit provided on September 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the reports attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 had network providers 
available who could have provided 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 an office visit provided on August 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there has been no non-invasive 
evaluation, as with a stress test, to assess for cardiac ischemia for this enrollee. Medical therapy with anti-
anginal medications has not been used.  The medical records provided do not support the rationale for this 
invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in the 
enrollee's clinical management. 
 
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 cardiac catheterization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies, hygienic wipes. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the requested incontinence supplies, hygienic wipes are medically necessary. The Plan denied your request. 
The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, hygienic 
wipes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 patient is stable with current treatment and should only require short-term 
additional acute care services that can safely be provided at the current facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 7, 2021, to October 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the items reported separately for 
unbundling were denied correctly as these services are not separately reportable. Included in routine services 
are the regular room, dietary (guest meals) and nursing services, minor medical and surgical supplies, medical 
social services, psychiatric social services, and the use of certain equipment and facilities for which a separate 
charge is not customarily made. The items PLEURYX W VAC BTLE and CPAP/BIPAP/HI FLOW DAILY 
denied correctly, as these were not found in the medical records during dates of service billed, and therefore 
cannot be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services provided to the enrollee from September 7, 2021, to October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, knee; complete, 4 or more views 
(CPT code(s): 73564-RT and 73564-LT) provided on July 5, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation indicates that a radiologic examination, knee; with AP and lateral 
views was performed. The Plan states there is a more appropriate CPT code (CPT 73560) that should be used 
to bill for a radiologic examination, knee; with AP and lateral views. 
 
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 73564 is radiologic examination, knee; complete, 4 or 
more views. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found procedure code 73564 RT - 
The documentation submitted was reviewed and does not meet criteria. Procedure report documents, "Xrays 
were taken today in the office both knees AP and lateral views". In this case, four (4) views cannot be verified. There is a more appropriate code to report for service provided. 
 
CPT 73564 LT - Documentation submitted was reviewed and does not meet criteria.  Procedure report 
documents, "Xrays were taken today in the office both knees AP and lateral views". In this case, four views 
cannot be verified. There is a more appropriate code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the radiologic examination, knee; complete, 4 or more views (CPT code(s): 73564-RT and 
73564-LT) provided on July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 15th, 2021, 
through December 22nd, 2021, and billed with diagnosis code N17.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code N17.9, acute kidney failure, unspecified is supported by the records. The Plan denied your 
request. The Plan says the documentation submitted does not support the primary diagnosis code N17.9, acute 
kidney failure, unspecified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code N17.9, acute kidney failure, 
unspecified. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the records submitted do not support the primary diagnosis code 
N17.9, acute kidney failure, unspecified. Our physician reviewer found there was no evidence of increase in 
baseline serum creatine documented by physician by 3.0 times baseline or a decrease in the Glomerular 
Filtration Rate over 75%. Kidney function improved with initial treatment. Therefore, diagnosis code N17.9 
acute kidney failure is not supported by the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 15th, 2021, through December 22nd, 2021, and billed 
with diagnosis code N17.9.
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 enrollee would benefit from intensive rehab prior 
to returning home. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 the enrollee has undergone uncomplicated spinal fusion and does not require 
intensive or complicated rehabilitation services. The enrollee's functional status is reasonably addressed at a 
level of care other than an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair (K0835) and the additional 
requested items (E2361, E1028, E1002, E0955, E1012, E0973, E2310 and E2601). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the enrollee is able to get out of a chair and walk. The enrollee does not have high risk for skin 
breakdown and the enrollee has 1+ edema, no spasticity and does not use intermittent catheterization; therefore, 
the LCD criteria have not been met. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair (K0835) and the additional requested items (E2361, E1028, E1002, 
E0955, E1012, E0973, E2310 and E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair. 
 
You asked the Plan to pre-approve an ultra-lightweight manual wheelchair. You say that the requested 
wheelchair was justified by the therapist. You say that the enrollee is a full-time wheelchair user as a result of 
post-polio, and requires an individualized fitting as noted, along with the items that require custom fitting. You 
say that the requested item is to replace the enrollee's current power wheelchair. The Plan denied your request. 
The Plan says the medical records do not show that the manual power wheelchair is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ultra-lightweight wheelchair is covered for certain 
medical indications and when 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 an ultra-lightweight manual wheelchair. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is 
limited in ambulation. The record does not provide specific evidence in support of the ultralight wheelchair. 
The documentation has general statements about comfort or stability but no specific information about why the 
enrollee's specific condition requires an ultralight wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultra-lightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 that the enrollee's functional status does not require intensive or complex 
rehabilitation. The enrollee does not require frequent physiatry oversight. The evidence based and clinical  
 practice standard of care for the enrollee's functional status and dementia challenges is manageable at a level of 
care other than an IRF. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for a laparoscopic procedure provided to the enrollee on April 
20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied procedure code is not supported by the records submitted. 
 
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 47379 is "Unlisted laparoscopic procedure, liver." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes a 
"Paraesophageal hernia repair with Nissen Fundoplication, excision of left liver mass." The operative report 
does not include documentation of an unlisted procedure, and therefore cannot be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a laparoscopic procedure provided to the enrollee on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a peripheral nerve injection with ultrasonic guidance 
provided to the enrollee on February 22, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this has been deemed 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no post-operative pain consult documented. The rationale for placing a peripheral block 
without a long-acting agent or catheter in the presence of a spinal is not clear. The procedure was not medically 
reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a peripheral nerve injection with ultrasonic guidance provided to the enrollee on February 22, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had extensive spinal surgery and due to your 
age, you need aggressive rehabilitation at an inpatient facility. The Plan denied your request. The Plan says an 
IRF admission 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 that the clinical documentation does not show any complex functional deficits or 
active medical issues (urinary retention resolved, anemia stable, pain managed) thus the complexity of your 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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 an IRF admission and services.