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

 
We decided that the Plan does not have to pay for the office visit and surgery provided May 26, 2020, to June 
4, 2020, by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for the office visit and surgery. You say that you would like these claims 
reprocessed and approved for payment based on previous history. The Plan denied your request. The Plan says 
the previous claim was paid in error. This is a provider who does not accept Medicare payments; therefore, no 
payment can be made. 
 
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 office 
visit and surgery provided May 26, 2020, to June 4, 2020, by a provider who has opted out of Medicare.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab services (82040, 82310, 82374, 82565, 82728, 
83540, 84100, 84132, 84295, 84460, 84466, 84520, 85014, 85018, 85025, 90999, J0882, J1644, J1756) 
provided June 1, 2020 to June 29, 2020. 
 
You asked the Plan to pre-approve the lab services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the provider was not enrolled at the time services were rendered. 
Additional documentation was requested and none was received. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The record shows a valid Medicare ID number was not provided with 
the claim. 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 pre-approve lab services (82040, 82310, 82374, 
82565, 82728, 83540, 84100, 84132, 84295, 84460, 84466, 84520, 85014, 85018, 85025, 90999, J0882, J1644, 
J1756) provided June 1, 2020 to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses you purchased September 30, 2020. 
You asked the Plan to pay for the eyeglasses. You say that your provider ordered you eyeglasses that you were 
under the impression were covered by the Plan. The Plan denied your request. The Plan says that eyeglasses are 
not a covered benefit. 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
You were referred for the eyeglasses by a contract provider. Your provider ordered these eyeglasses for you 
and stated that you had not yet used your benefit for eyeglasses or contact lenses after cataract surgery. 
Eyeglasses are an example of a service that is normally not covered but could be covered under some 
conditions. The file does not show that the Plan provided notice that the eyeglasses would not be covered. 
Under Medicare rules, this means the eyeglasses you purchased are considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the eyeglasses you purchased September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required provided. 
 
You asked the Plan to pay for the core buildup. You say that you were not advised that the treating provider 
had sold their practice prior to your appointment. You also say that you thought you were still in-network. The 
Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The crown you received on this date of service was paid for in full by 
the Plan. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins 
when required provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (A4557) provided September 18, 2020. 
 
You asked the Plan to pay for the lead wires. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary. 
 
We find that CPT code A4557 is not supported in the medical record. Specifically, the TENS unit was provided 
within the last 12 months. There are no medical records supporting the need for replacement leads. Based on 
this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, 
we decided that the Plan does not have to pay for lead wires (A4557) provided September 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea for the enrollee. 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no documentation of therapeutic failure on, intolerance to, or 
contraindication to Avastin. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee. There is no documentation of therapeutic failure on, 
intolerance to, or contraindication to Avastin. Our physician reviewer found that the enrollee's condition does 
not meet step therapy criteria for Eylea. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental 
status. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and waive the 
out of network cost share for the prophylaxis (D1110) and the bitewing x-rays (D0272) provided on September 
28, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and waive the out of network cost share for 
the prophylaxis and bitewing x-rays. You say that you were advised by a plan representative that the services 
would be covered at 100%. You say that you got a letter from the Plan saying that you were responsible for 
$145. You say that that is not 100%. You also say that you are sad because you cannot get a straight answer 
from the Plan. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 
years. The Plan says that the frequency limit for this service has been exceeded. The Plan says that the provider 
in this case is out of network. The Plan also says that out of network providers may bill you for any amount 
greater than the payment made by the Plan to the provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit for the 
comprehensive oral evaluation has been exceeded. The record shows that the Plan paid for a comprehensive 
oral evaluation that you received on July 8, 2019. Additionally, out of network providers may bill you for any 
amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150), nor waive the out of network cost share for the 
prophylaxis (D1110) and the bitewing x-rays (D0272) provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapy hot tub (E1399). 
 
You asked the Plan to pre-approve a therapy hot tub. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a therapy hot tub (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires provided on September 6, 2020. 
 
You asked the Plan to pay for the lead wires. You say that code A4557 can be billed separately. The Plan 
denied your request. The Plan says the replacement of lead wires more often than every twelve months is not 
reasonable and necessary. 
 
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 file shows that the enrollee received a TENS device, which includes lead wires, on January 6, 2020. We 
find that replacement lead wires are not supported in the medical record. The records provided do not indicate 
that the enrollee's device required replacement lead wires. 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 lead 
wires provided on September 6, 2020.
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 this is medically necessary. The Plan denied your 
request. The Plan says the medical condition must be of a level of complexity that requires an intensive and 
coordinated interdisciplinary approach including physician visits at least three times weekly. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
COVID 19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable ambulance supplies (A0382) provided on 
August 18, 2020. 
 
You asked the Plan to pay for the ambulance supplies. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items are not separately payable 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2006, items and services 
which include but are not limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and 
night differential are no longer paid separately for ambulance services.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance supplies have not been met. Specifically, these supplies are not separately payable 
from the ambulance transport. Therefore, we decided that the Plan does not have to pay for the disposable 
ambulance supplies (A0382) provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of a non-compounded foam sclerosant with 
ultrasound compression maneuvers to guide dispersion of the injectate. 
 
You asked the Plan to pre-approve an injection of a non-compounded foam sclerosant with ultrasound 
compression maneuvers to guide dispersion of the injectate. You say that the requested injection of a non-
compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested injection of a non-compounded foam sclerosant with ultrasound compression maneuvers to guide 
dispersion of the injectate. 
 
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 injection of a non-compounded foam 
sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate. Our reviewer says that 
the enrollee does not meet criteria for the requested injection of a non-compounded foam sclerosant with 
ultrasound compression maneuvers to guide dispersion of the injectate. Our physician reviewer found while 
there is documentation of a covered indication for vein treatment, the documentation does not meet LCD 
criteria for the procedure in question. The LCD criteria specifically does not consider sclerotherapy of large 
veins to be medically necessary due to the increased risk of treatment failure and recurrence. The vein in 
question is documented to be approximately 9 mm in diameter, well above the LCD criteria for sclerotherapy 
(<4mm). In fact, the physician?s assessment and plan notes a plan for ablation and does not mention 
sclerotherapy. There is no documentation of any contraindication to covered treatments for the enrollee's 
condition. 
 
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 injection of a non-compounded foam sclerosant with ultrasound compression 
maneuvers to guide dispersion of the injectate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an injection of a non-compounded foam sclerosant with ultrasound compression 
maneuvers to guide dispersion of the injectate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says goals have been met after 14 sessions of therapy. 
 
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 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 requested additional therapy is not generally accepted as specific 
and effective therapy for your condition. You have had extensive therapy for this condition and the 
documentation does not indicate that your functional level requires the unique skills of a professional therapist 
to safely and effectively provide treatment, or that the services can be safely and effectively performed only by 
a therapist, or under the supervision of a therapist. The documentation does not reveal measurable objective 
significant improvements in function or deficits that require ongoing skilled therapy. You are competent in a 
home exercise program. 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 your current condition or to prevent or slow further deterioration. 
 
 
 
 
 
 
 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the urography (74420) provided on May 29, 2020. 
 
You asked the Plan to pay for the urography. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
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 74420 is urography, retrograde, with or without KUB. 
 
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 urography. Our reviewer says that CPT code 74420 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did not 
include a radiology report to verify radiographic imaging. was performed. 
 
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 urography have not been met. Therefore, we decided that the Plan does not 
have to pay for the urography (74420) provided on May 29, 2020.