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

We decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on June 6, 
2020 and June 11, 2020. 
 
You asked the Plan to reimburse you for the eye exam and eyeglasses. You say that due to the coronavirus 
many providers were not open so you went back to your doctor and used your own funds. You say you asked 
the Plan for partial reimbursement as this doctor has a good reputation in your area. The Plan denied your 
request. The Plan says you must use a participating provider in order for vision services to be covered. 
 
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 covers these services when received from a participating provider. 
 
We looked at the file and the Plan's rules. The file shows that the provider in this case is not a participating 
provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eye exam 
and eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for an 
eye exam and eyeglasses provided on June 6, 2020 and June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from October 22, 
2020, and forward. 
 
You asked the Plan to pre-approve continued inpatient mental health care from October 22, 2020, and forward. 
You say that the requested inpatient mental health care from October 22, 2020, and forward is medically 
necessary. The Plan denied your request. The Plan says the requested inpatient mental health care from October 
22, 2020, 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 October 22, 2020, and forward. Our reviewer says that the requested inpatient mental health care from 
October 22, 2020, and forward is not medically necessary. Our physician reviewer found based upon review of 
the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
hospital unit beyond the date in question of October 22, 2020, and forward. The enrollee can been treated in a 
lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety as this enrollee was awaiting placement. 
 
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 October 22, 2020, and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient 
mental health care from October 22, 2020, and forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion. 
 
You asked the Plan to pre-approve spinal fusion.. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested 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 spinal fusion.. 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 back pain. The requested spacer device is considered experimental. More 
research is needed. There is no documented instability. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99203) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that the Plan does 
not have sub-specialists who focus on the pancreas. The Plan denied your request. The Plan says there are 
multiple in-network gastroenterologists who have expertise in complex cases that are available for you to 
obtain a second opinion. 
 
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 
the new patient office or other outpatient visit (99203) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Polar Care unit provided on February 3, 2020. 
 
You asked the Plan to pay for the Polar Care unit. You say that this equipment was essential to your shoulder 
healing correctly. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Polar Care unit have not been met. Therefore, we decided that the Plan does not have to pay for 
the Polar Care unit provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit (99350) provided on June 
26, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. You say that authorization should not be 
needed for telemedicine services. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient home visit (99350) 
provided on June 26, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta. 
 
You asked the Plan to pre-approve Vyzulta. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Vyzulta is not covered under the enrollee's Medicare Part B 
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 Vyzulta.  
 
Benefits for Vyzulta may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01992) provided on February 7, 2020. 
 
You asked the Plan to pay for anesthesia. You say that this was billed correctly. The Plan denied your request. 
The Plan says the use of anesthesia is not supported in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that local anesthesia or minimal conscious sedation 
may be appropriate with lumbar epidural injections. Use of moderate sedation and Monitored Anesthesia Care 
(MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific 
patient. 

We looked at the file and Medicare rules. The records do not clearly establish the need for the anesthesia used 
in this case. Based on this information, we decided that Medicare rules for coverage of anesthesia have not 
been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01992) provided on 
February 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
3, 2020, to February 12, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says payment is not allowed for these services because an invalid HIPPS code was billed. 
The Plan states that a corrected claim can be submitted for review.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted has an invalid 
HIPPS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for 
home health services provided to the enrollee from January 3, 2020, to February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the blood glucose test strips (A4253) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve blood glucose test strips. You say that what you were previously using was 
not user friendly and would like to try something new. The Plan denied your request. The Plan says you must 
receive care from a preferred manufacturer. 
 
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 
the blood glucose test strips (A4253) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CV risk assessment panel provided on April 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, 
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.  
 
We looked at the file and Medicare rules. The requested CV panel is non-covered per LCD L36523. 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 pay for the CV risk assessment panel provided on April 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroplasty services. 
 
You asked the Plan to pre-approve arthroplasty services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that total hip replacement is only covered for certain 
indications.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
support that the requested services are medically reasonable or necessary. Based on this information, we 
decided that Medicare rules for coverage of arthroplasty services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve arthroplasty services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic esophagogastroduodenoscopy 
(43239) and colonoscopy (45385) performed on June 10, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic esophagogastroduodenoscopy and colonoscopy. 
You say that you did not want these procedures done in the first place and would not have done them if you 
had known they were going to be diagnostic procedures. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery performed in an outpatient hospital facility.  
 
You have been asked to pay a $329.88 copayment for a diagnostic esophagogastroduodenoscopy and 
colonoscopy. Diagnostic procedures are distinct from routine screening procedures. A diagnostic 
esophagogastroduodenoscopy and colonoscopy fall within the "Outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers" benefit category. The case record shows that 
these procedures were performed in a hospital outpatient facility. This means that you have been asked to pay 
less than the full amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a diagnostic esophagogastroduodenoscopy (43239) and colonoscopy (45385) performed on June 
10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on May 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provided has opted 
out of Medicare. 
 
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 a provider that 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures provided on 
May 19, 2020. 
 
You asked the Plan to pay for the removable prosthodontic procedures. You say that you were not advised that 
only the one provider referred to you by the Plan was 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. Therefore, we decided that the Plan does not have to pay for the two 
removable prosthodontic procedures provided on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the continuation of acute care services is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not have a medical 
condition that is complex enough to require further hospital or special nursing care. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute hospital with bacteremia. She was seen in ER from 
dialysis for a blood sugar in the 30s, was treated and returned to dialysis center. Blood cultures were done, was 
notified of positive cultures, and called back to the emergency room. The enrollee is receiving appropriate care 
at the current acute care facility. The review has determined that the enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
February 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 Plan contract states outpatient mental health requires a 
referral.  
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the 
enrollee on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close respiratory 
monitoring, labs, physician visits, and rehab therapies. The Plan denied your request. The Plan says the enrollee 
still has an altered mental status and requires a sedating machine. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with an acute cerebrovascular accident 
(CVA). He required an intensive care unit level of care services with intubation and mechanical ventilatory 
support. He had issues with seizures. He is status post tracheostomy and PEG tube insertion. He remains 
ventilator dependent. The enrollee is receiving appropriate care at the current acute care facility. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.