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

 
We decided that the Plan does not have to pre-approve the blepharoplasty. 
 
You asked the Plan to pre-approve the blepharoplasty. You say that the blepharoplasty is medically necessary. 
The Plan denied your request. The Plan says the blepharoplasty 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 the blepharoplasty. Our reviewer says 
that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have any complaints that her activity of daily living is affected (e.g., 
reading, driving). Also, the records shows that the visual field testing does not demonstrate an improvement of 
12-15 degrees with taping. Therefore, criteria are not 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 blepharoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the blepharoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 24, 2022, to July 
27, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately. The Plan denied your request. The Plan says some 
diagnoses reported on this claim are not supported by the medical records provided. The Plan also says that this 
results in a change to the submitted DRG and payment rate. 
 
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 R78.81 (bacteremia) and E87.1 (hypo-osmolality 
and hyponatremia). 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 diagnosis codes, R78.81 and E87.1, are not 
supported. Our physician reviewer found during the hospital stay the diagnosis of bacteremia was not 
reasonably documented with a plan of care. An initial positive blood culture is documented; however, the 
documentation supports a contaminated specimen, and when retested it was normal. The diagnosis of hypo-
osmolality was not reasonably documented with a plan of care for the diagnosis reported. The laboratory report 
documents a low sodium level, however, care for diagnosis is not documented 
 
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 July 24, 2022, to July 27, 2022, at the DRG originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental 
pneumatic appliance, full leg (E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and an appliance. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the enrollee must 
receive services and items from a network provider. There are in-network providers within a reasonable 
distance from the enrollee's location that can provide this item. 
 
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 pneumatic compressor (E0651) and a segmental pneumatic appliance, full leg (E0667) to be provided by an 
out-of-network (OON) provider.
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 in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have 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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy to be provided by the requested provider. 
 
You asked the Plan to pre-approve the psychotherapy. You say that your claims were paid for from this facility 
for the last two years. You say that it is very important that you continue these services as these services are 
very helpful to you and for your mental wellbeing. The Plan denied your request. The Plan says under the 
Medicare rules, the request for payment by a Licensed Clinical Professional Counselor (LPC) is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy to be provided by 
the requested provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 that you are responding to the current treatment and only require short-term 
additional acute care services that can safely be provided at the current facility until you are more appropriate 
for transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee receives 
chemotherapy and radiotherapy treatment for lung cancer daily and does not have transportation at home. The 
Plan denied your request. The Plan says the enrollee has exhausted her benefit limit for the year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
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 the enrollee's clinical condition meets full IRF 
criteria. You also say the lower level of care in skilled nursing cannot provide the total interdisciplinary team 
approach needed and does not provide the medical management/intensive therapy program the enrollee needs 
to return home safely. The Plan denied your request. The Plan says an IRF admission is not supported based on 
the records received. 
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
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 are appealing the denial with supporting 
medical records. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 that the enrollee does not require daily skilled nursing services. The enrollee is 
functioning at a home care level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says  the VIA Disc 
procedure 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 the procedure. Our reviewer says that 
the VIA Disc procedure is not medically necessary. Our physician reviewer found the VIA Disc procedure is 
considered experimental for back pain. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device (E1399). 
 
You asked the Plan to pre-approve a Volara device. You say that the enrollee needs The Volara System. 
Airway clearance therapy is an essential component of enrollee's daily care plan. The Plan denied your request. 
The Plan says use of the VolaraTM Device in the in-home setting is considered experimental/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 a Volara device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has no documented indication that the chest physiotherapy or alternative therapies 
have been used or failed. The enrollee has no documented indication that the chest physiotherapy or alternative 
therapies have been used or failed. There is no data to indicated Volara is superior to alternative therapies. 
 
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 Volara device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara system-high frequency oscillation lung expansion device (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transportation to a physician's office. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs a stretcher for 
transportation. The Plan denied your request. The Plan says a physician's office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 The requested services, ambulance transport services to a doctors office, is not a covered benefit. Therefore, 
we decided that the Plan does not have to pre-approve ambulance transportation to a physician's office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conservative 
treatment without relief. The Plan denied your request. The Plan says the enrollee does not meet evidence-
based criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97022 rendered on January 10, 2023. 
 
You asked the Plan to pay for procedure code 97022. You say that medical records were submitted for review. 
The Plan denied your request. The Plan says procedure code 97022-GP-59 remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 97022. Our reviewer says 
that the use of modifier 59 is not supported. Our physician reviewer found that the procedure report documents 
that "Prior to the nail debridement, the patient was first asked to soak their feet in a hydrotherapy bath for 
greater than 8 minutes to help improve circulation, reduce inflammation, relieve any pressure stored in the 
tissues of the patient's feet, and soften the nails and surrounding tissue. Per Medicare, if the enrollee uses a 
whirlpool for treatment of a wound prior to receiving selective debridement services for the wound during the same visit, then the whirlpool is not separately reimbursable and should not be billed with modifier 59 unless 
two separate wounds are treated with the different modalities.  In this case, claim denied correctly as modifier 
59 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97022 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97022 rendered on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's mammogram services provided on 
January 25, 2023. 
 
You asked the Plan to pay for the physician's mammogram services. You say that for the past 25 plus years you 
have diligently made yearly mammography appointments with this provider and you have never been made 
aware that this provider opted out of Medicare. The Plan denied your request. The Plan says this provider is a 
Medicare opt out provider and not eligible to be part of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
physician's mammogram services provided on January 25, 2023.