Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty, upper eyelid; with excessive skin 
weighting down lid (15823). 
 
You asked the Plan to pre-approve blepharoplasty. You say that the procedure is medically necessary. The Plan 
denied your request. The Plan says records did not show visual field interference or impairment or reading 
difficulty and photo documentation of eyelids which is affecting the vision. n appeal, the provider sent 
documentation of vision impairment but there was no photo documentation of the eyelids. Therefore, medical 
necessity has not been established for the requested services. 
 
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 blepharoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has dermatochalasis. The record provided documents that 
"vision is o" after cataract surgery and no functional impairment is noted. The record provided does not include 
photographs or MDR1 measurements. The record provided is insufficient to establish the medical necessity of 
the requested service at this time. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce your coinsurance for the outpatient diagnostic services. We decided 
that the Plan does not have to waive your coinsurance for the inpatient hospital services.  
 You asked the Plan to waive your coinsurance for the inpatient hospital services provided from April 27, 2022, 
to April 28, 2022, and to reduce the coinsurance for the outpatient diagnostic services provided from April 18, 
2022, to May 9, 2022. You say that you would like the Plan to reconsider your request. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan must reduce your coinsurance for the outpatient diagnostic services.  
 
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% 
coinsurance for outpatient diagnostic services provided by an out-of-network provider. The file shows that 
more than a 40% coinsurance applied to each Outpatient claim. Therefore, we decided that the Plan must 
reduce your coinsurance for the outpatient diagnostic services.  
 
We also decided that the Plan does not have to waive your coinsurance for the inpatient hospital services. 
 
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% 
coinsurance for inpatient hospital services provided by an out-of-network provider. The file shows that you 
were correctly charged a 40% coinsurance for the Inpatient claim. Therefore, we decided that the Plan does not 
have to waive your coinsurance for the inpatient hospital services. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee recently fell, broke his hip and now has 
a urine infection from the surgery. A skilled nursing facility cannot provide the treatment that a rehab could. 
The Plan denied your request. The Plan says that admission was denied as not meeting criteria and the enrollee 
can safely receive services in the current setting until the hospital course has been completed. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Given the enrollee's ongoing infection, 
anemia, and urinary retention, he would benefit from rehabilitation physician oversight provided in the acute 
inpatient rehabilitation setting. The enrollee requires rehabilitation nursing for wound care and bowel and 
bladder management. The needs of the enrollee require an intensive interdisciplinary approach provided on an 
acute inpatient rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 21, 
2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to 
the services of a physician/NPP also must meet all incident-to requirements.  
We find that CPT code 97110 is not supported in the record. Specifically, the record shows that this claim was 
billed by a nurse practitioner and the services were rendered by a physical therapist. A nurse practitioner cannot 
bill for the services of a physical therapist. Therefore, we decided that the Plan does not have to pay for the 
physical therapy services provided on September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is no gap coverage. The Plan also says that there are 
in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an injection. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an injection to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 the enrollee is being treated for 
spondylosis without myelopathy or radiculopathy, other intervertebral disc degeneration of the lumbar spine, 
and vertebrogenic low back pain. In this case, there are multiple plausible pathologic sources of significant pain 
generation. The documentation is lacking regarding reasonably detailed and/or evidenced findings supportive 
of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. The Intracept procedure is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that you have severe 
back issues and are in quite a bit of pain. You say that this is approved by Medicare, but the Plan denied this as 
experimental and investigational. The Plan denied your request. The Plan says radiofrequency ablation of the 
sacroiliac joint is considered experimental or 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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that this procedure is considered experimental due to 
the wide variation in efficacy published in the peer reviewed literature. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), coronavirus test (87635), and 
additional supplies, materials, and clinical staff time over and above those usually included in an office visit or 
other non-facility service (99072) provided on December 14, 2020. 
 
You asked the Plan to pay for the physician services. You say that you thought the coronavirus tests were free. 
You say that you do not understand why it did not get covered. The Plan denied your request. The Plan says the 
claim processed correctly. 
 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 has made 
attempts to contact the provider to advise the bill needs to be sent to the primary insurer. As the secondary 
insurer, the Plan cannot be held responsible for the physician services until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99213), 
coronavirus test (87635), and additional supplies, materials, and clinical staff time over and above those usually 
included in an office visit or other non-facility service (99072) provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on May 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 x-ray provided on May 9, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on April 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81455 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81455) provided on April 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records do not document the enrollee needs intravenous (IV) medications, new 
tube feedings, ostomy care, daily complex wound care, or respiratory care. She has no skilled nursing needs. 
She is walking household distances with a rolling walker and contact guard assistance and needs stand-by 
assistance for transfers. The records do not document a significant decline in her functional states. She does not 
require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary 
services on an inpatient basis at the SNF level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the home ventilator is medically necessary. 
The Plan denied your request. The Plan says your request is not medically necessary because your records 
show your device is prescribed as a CPAP/APAP mode device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have severe obesity and were 
hospitalized in August with acute NSTEMI and exacerbation of HFpEF. ABG was consistent with acute on 
chronic hypercarbic respiratory failure, due to obesity hypoventilation syndrome.  A diagnosis of asthma is 
mentioned, although spirometry was consistent with restriction without obstruction, so this diagnosis is not 
confirmed. There were no lung volumes to confirm restriction. Notes in the record indicate you did better in 
CPAP than on BiPAP in the hospital. There is a previous history of OSA, treated with BiPAP. You may benefit 
from a PAP titration sleep study, and either CPAP or BiPAP during sleep as an outpatient. A home ventilator is 
not necessary for the treatment of OHS.  Medicare does not cover a home ventilator for this purpose, or when 
used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
 You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need the portable oxygen 
generator. Most of the time (90%), you use your walker outside, such as light yard work or even going for 
walks. The Plan denied your request. The Plan says they will not preauthorize a portable oxygen concentrator 
for you. You have been provided with oxygen equipment that meets your needs. You have not been evaluated 
by respiratory therapy for a portable oxygen concentrator. You will be offered lightweight tanks and an oxygen 
conserving device. 
 
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 a portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have restrictive lung disease and are apparently on home oxygen, 
although no information about that is provided. There is no documentation in the clinical notes of the need for a 
POC. The Plan indicates you will be offered small tanks with an oxygen conserving device. The small tanks 
can be carried on the walker. Medicare approval of a POC requires documentation that SpO2 can be 
maintained >91% during activity using an oxygen conserving device at 1 to 4 Lpm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 18, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 laboratory 
services (0037U) provided on January 18, 2022.