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

 
We decided that the Plan does not have to pay for the vision supply and the medical eye examination. 
 
You asked the Plan to pay for the vision supply . You say that you are unsure about who should be covering 
this bill. You say you went to see a specialist because you needed a follow-up.  The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not listed in the supplemental benefits. 
Based on this information, we decided that the Plan's rules for coverage of the vision supply have not been met. 
Therefore, we decided that the Plan does not have to pay for the vision supply and the medical eye 
examination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and a harness 
(E2313). 
 
You asked the Plan to pre-approve an expandable controller and a harness. You say that the requested items are 
medical necessary for the enrollee. The Plan denied your request. The Plan says the requested items 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 a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee has adequate strength to manage the standard power 
drive controls. The requested expandable controller with a harness is not medically necessary to meet the 
enrollees needs. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377) and a harness (E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care from June 2, 
2023, and forward. 
 
You asked the Plan to pre-approve continued inpatient mental health care from June 2, 2023, and forward. You 
say that the request for continued inpatient mental health care from June 2, 2023, and forward is medically 
necessary.  The Plan denied your request. The Plan says the request for continued inpatient mental health care 
from June 2, 2023, and forward is not medically necessary.   
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health care 
from June 2, 2023, and forward. Our reviewer says that the request for continued inpatient mental health care 
from June 2, 2023, and forward is not medically necessary.  Our physician reviewer found based upon review 
of the records provided it was not expected this enrollee would improve in a reasonable period beyond the 
dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. The enrollee was not showing any behaviors or aggression and he was being cooperative and 
compliant while not showing any acute threats to safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or 
abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did 
not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health care from June 2, 2023, and forward have not 
been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health 
care from June 2, 2023, and forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve dialysis to be provided by an OON provider. You say that the services 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 
dialysis 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 pay for the hospital discharge day management; more than 30 
minutes (99239) provided from January 10, 2023, through January 18, 2023.  
 
You asked the Plan to pay for the service. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says code 99239 is not supported by documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 service. Our reviewer found the medical records do not indicate the level of the discharge being greater than 30 minutes spent, no time is listed; therefore, the best code 
as per the documentation is 99238. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge day management; more than 30 minutes (99239) provided from January 
10, 2023, through January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-XU, 87481, 87641-XU, and 87653-
XU billed for date of service December 27, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes remain 
not supported. 
 
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 87150-XU is a column II code to column I code 87500, code 87481 
is a column II code to column I code 87801, code 87641-XU is a column II code to column I code 87801, and 
code 87653-XU is a column II code to column I code 87801. Code 87481 has not been billed with an 
appropriate modifier to bypass the edit. The records do not show that the codes 87150, 87641, and 87653, 
billed with an -XU, were unusual non-overlapping services. A modifier should not be billed just to bypass an 
edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87150-XU, 87481, 87641-XU, and 87653-XU billed for date of 
service December 27, 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 need further rehabilitation. The Plan denied 
your request. The Plan says this 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left phlebectomy (37766). 
 
You asked the Plan to pre-approve left phlebectomy (37766). You say that the requested left phlebectomy 
(37766) is medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested left phlebectomy (37766). 
 
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 left phlebectomy (37766). Our reviewer 
says that the enrollee does not meet criteria for the requested left phlebectomy (37766). Our physician reviewer 
found for tributary treatment such as stab phlebectomy to be considered medically necessary per coverage 
criteria, there needs to be persistent significant symptoms following successful treatment of truncal (saphenous) 
reflux with these symptoms existing more than 6 weeks after the reflux was treated and despite conservative 
efforts.  Additionally, the veins to be treated need to be at least 4 mm in diameter.  As the enrollee has not yet 
undergone saphenous vein reflux treatment, the above criteria have not been met.  The health plan does not 
provide for simultaneous saphenous reflux treatment and tributary treatment.  A rationale for this is that many 
patients experience satisfactory relief with the truncal intervention alone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left phlebectomy (37766) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left phlebectomy (37766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cranial prosthesis (A9282). 
 
You asked the Plan to pre-approve the cranial prosthesis. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this item is considered a wig and is non-covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a cranial 
prosthesis (A9282).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. At this point, the enrollees care needs are custodial and can, as a practical matter, be 
provided at 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 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 enrollee requires this device, which the 
health care team has ordered to help prevent continued pulmonary exacerbations and hospitalizations. The Plan 
denied your request. The Plan says this request for a home mechanical ventilator set in assist-control mode with 
very low tidal volumes that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 for the enrollee. Our physician reviewer found 
the record indicates that the enrollee has chronic respiratory failure from COPD in the setting of lung cancer. 
The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. Our reviewer found that the enrollee could be treated with a BiPAP 
machine with average volume-assured pressure support (AVAPS) capability and failure of such a device has 
not been documented. The elements of the coverage criteria are not satisfied. Our physician reviewer also 
found that the requested service cannot be 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
October 11, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481 and 
87653 are bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for 
date of service October 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 7 physical therapy (PT) sessions.  
 
You asked the Plan to pre-approve the therapy services. You say that you require additional physical therapy 
visits after your knee replacement. The Plan denied your request. The Plan says the additional PT visits are not 
reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee 
has had instruction in a home exercise program. No further skilled therapy is required 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 7 physical therapy (PT) sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of excess tissue (lipectomy) around the 
abdomen (11981, 15839, 15830, 15734). 
 
You asked the Plan to pre-approve surgical removal of excess tissue around the abdomen. You say that you 
need this surgery because this skin has been affecting you physically and psychologically for many years. The 
Plan denied your request. The Plan says this surgery would be considered cosmetic as documentation does not show you have complicating factors as inability to walk normally, chronic pain, ulceration created by the 
abdominal skin fold, or intertrigal dermatitis. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable. The rules say that abdominal lipectomy/panniculectomy may be considered reconstructive when it is 
performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created 
by the abdominal skin fold, or intertrigal dermatitis, which must have been present for at least 3 months. 
 
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 surgical removal of excess tissue 
around the abdomen. Our reviewer says that these services do not meet the criteria for medical necessity in this 
case. Our reviewer found the record indicates that you have excessive skin in the setting of obesity. The record 
provided does not indicate the presence of complicating factors such as inability to walk normally, chronic 
pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, that have been present for at least 
three months and are refractory to usual standard medical therapy. 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 surgical removal of excess tissue around the abdomen have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgical removal of excess tissue (lipectomy) 
around the abdomen (11981, 15839, 15830, 15734).