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

 
We decided that the Plan does not have to pay for progressive lens (V2781) provided on August 8, 2020. 
 
You asked the Plan to pay for progressive lens. You say that you fell and broke your pair and needed a new 
pair. The Plan denied your request. The Plan says you have exceeded the maximum benefit per period and are 
responsible for the full cost of this service. 
 
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 standard lenses and frames, limited to one pair every two years. 
 
We looked at the file and the Plan's rules. You have exceeded the maximum benefit limitation. Based on this 
information, we decided that the Plan's rules for coverage of progressive lens have not been met. Therefore, we 
decided that the Plan does not have to pay for progressive lens (V2781) provided on August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a LifeVest provided to the enrollee on December 5, 2019. 
 
You asked the Plan to pre-approve the vest. You say that you are the sole provider of the LifeVest worldwide. 
The Plan denied your request. The Plan says that Medicare says non-urgent services should be from network 
providers who are contracted with the health plan and listed in the Provider Directory. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
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 vest. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance, there is potential for recovery of left ventricular function over time with medical 
therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or 
inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Coverage criteria 
above are met since one covered indication includes "either documented prior myocardial infarction or dilated 
cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 0.35." 
 
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 vest have been met. Therefore, we decided that the Plan has to pre-approve 
a LifeVest provided to the enrollee on December 5, 2019.  
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a microslide consultation (88321) provided on June 18, 2020. 
 
You asked the Plan to pay for the microslide consultation. You say that you would like reconsideration because 
this service was medically necessary and billed correctly. The Plan denied your request. The Plan says CPT 
code 88321 has an MUE value of 1 but billed 2 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 88321 is one. You billed two units of this code, exceeding the MUE. Based 
on this information, we decided that Medicare rules for coverage of the microslide consultation have not been 
met. Therefore, we decided that the Plan does not have to pay for a microslide consultation (88321) provided 
on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee's facility will not be able to drive 
him to dialysis that is far away. The Plan denied your request. The Plan says the enrollee's network has the 
capability to provide the needed dialysis. 
 
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 contract providers 
located within reasonable distance and travel time who can provide the services at issue. We found no 
exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan 
does not have to pre-approve dialysis services 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to go to a place that is appropriate 
to take care of the medical problems. The Plan denied your request. The Plan says the enrollee has not 
completed the full course of treatment in the hospital. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for weakness. He was treated for cholecystitis and had 
coronary artery bypass surgery. His medical problems are stable. 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 medical record supports a need for physical and occupational therapy, but 
it does not support a need for an intensive rehabilitation therapy program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator (E0745) provided on June 
15, 2020. 
 
You asked the Plan to pre-approve a neuromuscular stimulator. You say that this was medically necessary. The 
Plan denied your request. The Plan says the documentation indicates this was not 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 neuromuscular stimulator. Our 
reviewer says that the requested item was not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation in the case file does not support that the requested neuromuscular 
stimulator, electronic shock unit was medically reasonable and necessary for the enrollee in this case. A 
physical examination of the ankles and feet would reasonably be required to adequately assess whether the 
coverage criteria were met. The documentation does not support that the stimulator was medically reasonable 
and necessary in this case, as there is insufficient documentation of a credible physical examination of the 
ankles and feet. 
 
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 neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a neuromuscular stimulator (E0745) provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pre-approve a power seat elevation system, USB charger, 
expandable controller, access harness, and electrical connection for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records document that the enrollee is independent with dressing, grooming, 
hygiene, meal preparation and eating. Strength and function of her upper extremities appear to be sufficient to 
operate the power options using their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. The seat elevator and the USB charger do 
not serve a primarily medical purpose. The enrollee does not medically need the other accessories. Based on 
this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power seat elevation system, USB charger, expandable 
controller, access harness, and electrical connection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vacuum erection device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) and related 
accessories (L7902) are statutorily non-covered. 
 
We looked at the file and Medicare rules. The services at issue are a vacuum erection device. These services 
are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the vacuum 
erection device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on July 14, 2020, from an OON 
provider. 
 
You asked the Plan to pay for hearing aids. You say that a representative of the Plan told you to go ahead and 
purchase from the OON provider. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only items/services are received from a participating provider. 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 hearing aids purchased on July 14, 2020, from 
an OON provider.  
 
Your complaint about receiving erroneous or misleading information from a representative of the Plan is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary. The Plan denied your 
request. The Plan says in the absence of a osteoporosis related fracture, a trial of Zoledronic acid is required 
before alternative drugs can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found there was no documentation of a trial of the plan 
preferred drug or any evidence that the plan preferred drug would be unsafe or ineffective for the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided by a chiropractor from May 23, 2020 
to June 26, 2020. 
 
You asked the Plan to pay for office visits. You say that you are requesting coverage for these services. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these 
services are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for office visits provided by a chiropractor from May 23, 2020 to June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on April 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this should be covered due to the COVID-19 
guidance. The Plan denied your request. The Plan says this was not authorized. 
 
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 office visit (99213) provided on April 14, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on June 
21, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation indicates the services are not necessary for treatment of the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
provided to the enrollee on June 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services 
provided on June 17, 2020. 
 
You asked the Plan to waive the copayment for the emergency department services. You say that you were not 
treated so you should not have a copayment. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency department services. The emergency 
department services fall within the Emergency Care benefit category. This means that you have been asked to 
pay the correct 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 the emergency department services provided on June 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary, and does not meet the Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse or qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment.  

The enrollee does not require the services on an inpatient basis, in a skilled nursing facility setting.  Services in 
a long-term care facility on a part time basis appear appropriate in this case. 

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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27487, 27899) provided April 2, 2019. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services 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 codes 27487 & 27899 are Revision of total knee arthroplasty, 
with or without allograft; femoral and entire tibial component and Unlisted procedure, leg or ankle. 
 
We find that CPT code 27487 & 27899 is not supported in the medical record. Specifically, there is a more 
appropriate primary code which includes revision of total knee arthroplasty. CPT code 27899 is not supported 
in the operative report. Based on this information, we decided that Medicare rules for coverage of the surgical 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
(27487, 27899) provided April 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for drugs (96365, 99214, J1200, J1569) 
provided April 15, 2020 to April 21, 2020. 
 
You asked the Plan to waive the coinsurance for the drugs. You say that you reached your out-of-pocket 
maximum at the time services were rendered. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a 20% coinsurance for Part B drugs and a $30 copayment for specialist 
visits. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $30 copayment for specialist visits. At 
the time the services were rendered, the out-of-pocket maximum had not yet been met. This means that you 
have been asked to pay the correct 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 coinsurance for drugs (96365, 99214, J1200, J1569) provided April 15, 2020 to 
April 21, 2020.