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

 
We decided that the Plan does not have to pre-approve rhinoplasty surgery. 
 
You asked the Plan to pre-approve rhinoplasty surgery. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the requested surgery services are considered cosmetic in nature. 
 
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 rhinoplasty surgery. 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 is status post nasal reconstruction including a 
right sided lateral crural onlay graft for nasal obstruction. The record indicates that the requested procedure is 
to improve appearance. and may have adverse functional impact. The requested procedure is cosmetic in 
nature. 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 rhinoplasty surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve rhinoplasty surgery.
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 the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested service would not be covered 
as the enrollee was enrolled in a federal Medicare-certified Hospice Program in which he revoked on March 
14, 2022.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 14, 2022. The services in question were requested 
before the end of that month. Therefore, we decided that the Plan does not have to pre-approve admission to a 
skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0651) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pay for intermittent limb compression device and appliance. You say that you feel as 
though additional care in the form of long-term daily home compression pump therapy is warranted at this time 
in order to maintain proper management of this chronic condition. The Plan denied your request. The Plan says 
the records do not support that the requested PCD is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device and 
appliance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found recent notes describe the enrollee responding and seeing 
improvement in her wounds following conservative treatments including compression wraps and basic wound 
care treatment. There was no evidence of a full 6-month trial and failure of conservative wound care treatment 
to justify this request. Therefore, the pneumatic compression device will be considered not medically necessary 
based on provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device and appliance have not been met. 
Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0651) and 
segmental pneumatic appliance (E0667).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revlimid for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited to those covered under the medical benefit. 
 
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 Revlimid for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid injections 
(TFESIs). 
 
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 a TFESI is covered when specific criteria are 
met. 
 
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 has a history of radicular 
low back pain. The pain is rated at nine out of 10 in the lower back with radiation to both lower extremities. 
She has been treated with medical therapy, physical therapy, and a home exercise program. The request is for 
bilateral TFESIs at two nerve root levels, which is not covered by the Medicare criteria. The services are 
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 bilateral transforaminal epidural steroid injections (TFESIs).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
January 6, 2021, to January 18, 2021. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that the enrollee should not 
be responsible for the inpatient copayments due to a mistake made at the skilled nursing facility. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $335 copayment per day for days 1-6 for an inpatient hospital stay. The Plan contract also says 
there is a $0 copayment for days 7-90. 
 The enrollee has been asked to pay a total of $2,010, which is a $335 copayment for days 1-6 of an inpatient 
hospital stay ($335 copayment x 6 days = $2,010). There is no copayment for days 7-90. An inpatient hospital 
stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for an inpatient hospital stay provided from January 6, 2021, to January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this item is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met as the documentation 
does not indicate that the member requires frequent and immediate need for a change in body position. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically reasonable and necessary. Our physician 
reviewer found based on the medical records provided there is documentation that you require a hospital bed 
for adjustment of the head of the bed due to your chronic lung disease. In addition, the medical records 
provided indicate there is documentation that you require frequent changes in body position. However, records 
do not document that you can operate the controls and cause the adjustments as required. There is no 
documentation that your condition requires special attachments that cannot be fixed and used on an ordinary 
bed. The requested semi-electric hospital bed is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supervision of a nursing facility patient (99379) provided on 
August 10, 2021. 
 
You asked the Plan to pay for supervision of a nursing facility patient. You say that the medically necessary 
services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules 
for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT code 99379 has a status indicator of B. This means that the payment for 
99379 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of supervision of a nursing facility patient have not been met. 
Therefore, we decided that the Plan does not have to pay for supervision of a nursing facility patient (99379) 
provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study provided on August 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 93976 may be eligible for payment when billed with 
CPT code 76856. The claim information does not show that the code at issue was billed with a modifier 
suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the vascular study provided on August 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is necessary for your 
condition. The Plan denied your request. The Plan says a home ventilator is not medically reasonable and 
necessary. 
 
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 a home ventilator is not medically reasonable and necessary as the criteria for coverage have not been met. 
Our physician reviewer found that a home ventilator is not medically necessary. You have had 2 recent 
hospitalizations for acute-on-chronic respiratory failure, with CO2 retention that resolved on bi-level positive 
airway pressure (BiPAP). The patient has a history of asthma, and a diagnosis of obesity-hypoventilation syndrome. Spirometry is very poor quality. The patient may benefit from BiPAP at night. But Medicare does 
not cover a home ventilator when used as BiPAP, and some BiPAP devices can provide the average volume-
assured pressure support (AVAPS) mode of support. 
 
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.
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 member would benefit from rehabilitation 
services. The Plan denied your request. The Plan says documentation submitted does not show that the member 
requires intensity of services provided at 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 there is not a reasonable expectation that the member 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: 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 records do not support that the 
spinal vertebral bodies are the primary sources of your chronic persistent pain. There are multiple other 
possible sources of the significant pain generation. The records do not support that the Intracept procedure is 
reasonable or medically necessary at this time. 
 
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 a Neo-Barostim device. 
 
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 has cardiomyopathy with 
congestive heart failure. The requested Barostim device is considered experimental/investigational in nature 
and 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 a Neo-Barostim device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional resources above those usually included in an 
office visit (99072) provided on September 10, 2021. 
 
You asked the Plan to pay for additional resources. You say that the services at issue were a necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This means that the payment for 
99072 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of additional resources have not been met. Therefore, we decided that 
the Plan does not have to pay for additional resources above those usually included in an office visit (99072) 
provided on September 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you request reconsideration of the Plan's denial for 
SNF care. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage. 
 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 daily 
skilled services are not necessary. Our physician reviewer found 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. 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 5, 2021, through 
November 7, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that this claim was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to substantiate their 
denial. The Plan has indicated that this claim was not billed in accordance with Medicare rules for billing of 
outpatient claims. This claim is an inpatient claim. There is no indication as to why this claim was billed 
incorrectly. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for inpatient hospital services provided on November 5, 2021, through November 7, 2021.  
 
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 the lab testing services provided on May 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists a place of service as an independent laboratory. We looked at he file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not indicate the specimen was obtained at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on May 4, 2021.