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

 
We decided that the Plan does not have to pay for an x-ray provided on September 20, 2021, to September 21, 
2021, 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 September 20, 2021, to 
September 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of the Vertiflex Superion device. 
 
You asked the Plan to pre-approve insertion of the Vertiflex Superion device. You say that insertion of the 
Vertiflex Superion device is medically necessary for back pain. The Plan denied your request. The Plan says 
insertion of the Vertiflex Superion device 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 insertion of the Vertiflex Superion 
device. Our reviewer says that insertion of the Vertiflex Superion device is not medically necessary. Our 
physician reviewer found that the Vertiflex Superion device is experimental. More research is needed. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of the Vertiflex Superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of the Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 11, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions 
are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on April 11, 2022.
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 the enrollee needs 24 hour nursing supervision and 
physical medicine and rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
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 with chronic medical problems, including lupus and a history of 
colon cancer presented to the acute hospital for revision of her R hip replacement because she was having 
recurrent dislocation. She was continued on her home medications and had an uncomplicated surgery. The 
enrollee did not have a complicated or unstable medical condition or complicated hip replacement. There is no 
evidence based support for an intensive rehabilitation for hip replacement and the enrollee has reduced capacity 
for therapy. 
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 multiple fractures can sometimes be an IRF compliant diagnosis and evaluating 
therapist do recommend intense rehabilitation however, there is no clinical documentation of "active comorbidities" that require close medical monitoring. Thus, not all IRF criteria are met and IRF is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that the enrollee cannot remain in an acute care 
facility because they need more of a long term care. The Plan denied your request. The Plan says based on 
Medicare guidelines the skilled nursing facility services you are requesting do not meet the requirements for 
approval. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee continues to benefit from multidisciplinary 
therapies and continues to meet criteria for IRF. The enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SNF admission.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts to be provided by an OON provider. You say that 
the items are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
diabetic shoes and inserts to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of blepharoptosis (67901-50) provided on 
February 4, 2022. 
 
You asked the Plan to pay for the repair of blepharoptosis. You say that the diagnosis is correct for this 
procedure and should be paid. The Plan denied your request. The Plan says this claim has denied because it was 
billed with an inappropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. The rules say that if 
no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. 
 
In this case, the CPT Code Manual definition of code 67901 is repair of blepharoptosis; frontalis muscle 
technique with suture or other material (eg, banked fascia). 
 
We looked at the file and Medicare rules. In this case, the diagnosis codes that have been billed are H02.422 (myogenic ptsosis of left eyelid) and H02.421 (myogenic ptosis of right eyelid). However, there is an ICD-10-
CM code that specifies a bilateral diagnosis, H02.423 (myogenic ptosis of bilateral eyelids). Therefore, this 
service has not been billed with the most appropriate diagnosis code. Based on this information, we decided 
that Medicare rules for coverage of the repair of blepharoptosis have not been met. Therefore, we decided that 
the Plan does not have to pay for the repair of blepharoptosis (67901-50) provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for travel and lodging expenses provided from 
November 17, 2020, to February 9, 2021. 
 
You asked the Plan to reimburse you for travel and lodging expenses. The Plan denied your request. The Plan 
says the services billed were to treat the members underlying chronic health condition of Sarcoidosis and 
therefore is not transplant related. The member does not have travel and lodging benefits for non-transplant 
related care. 
 
The Plan contract covers transplant services at a location outside of the pattern of care for transplants in your 
community. The Plan says that under certain conditions, the following types of transplants are covered: 
corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and 
intestinal/multivisceral. We looked at the file and the Plans rules. The file shows your Plan does not have travel and lodging benefits 
for non-transplant related care. Therefore, we decided that the Plan does not have to reimburse you for travel 
and lodging expenses provided from November 17, 2020, to February 9, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxervate. 
 
You asked the Plan to pre-approve Oxervate. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxervate.  
 
Benefits for Oxervate 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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is 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 you 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled 
nursing needs. You do have documented skilled therapy needs. While you are ambulating, the distance and 
quality of your ambulation is below your baseline. As you live alone, safety and practicality are of concern. A 
period of daily skilled services is reasonable to establish a maintenance program, prevent deterioration of your 
condition and maximize a return to your prior level of function. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
   
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81161, 81286, 81413, 81414, 81442, and 
81479 billed for date of service December 3, 2021. 
 
You asked the Plan to pay for procedure code 81161, 81286, 81413, 81414, 81442, and 81479. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
payment for code 81161 is bundled into payment for code 81413. Codes 81286, 81413, 81414, 81442, and 
81479 were requested for screening purposes. 
 
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 81161 
is a column II code to column I code 81413. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
The rules also explicitly say that screening tests are not covered. The test at issue in this appeal was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 81161, 81286, 81413, 81414, 
81442, and 81479 billed for date of service December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided 
to the enrollee on February 7, 2022. 
 
You asked the Plan to pay for the servcies. You say that this should be paid for. The Plan denied your request. 
The Plan says per standard coding guidelines, this is not billed appropriately. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
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 servcies. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records document that sedation was provided in an emergency department - hospital. In this case, CPT 99153 would not be 
separately reported, as this is a technical component only code, which the facility is reimbursed for this service. 
 
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 servcies have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on February 7, 
2022.