Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on 
June 2, 2020. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you should not have a 
copayment for a routine eye exam. The Plan denied your request. The Plan says this processed 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 $35 
copayment for Medicare-covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $35 copayment for a medical eye exam. The record shows that the exam in 
question was a Medicare-covered exam to diagnose and treat diseases of the eye. 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 a medical eye exam (92014) provided on June 2, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 90912) you received on January 2, 2020. 
 
You asked the Plan to pay for the services. You say that you were referred for these services. The Plan denied 
your request. The Plan says that this is 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 and provided the services by a contract provider. You had the reasonable expectation 
that the services in question would be covered. The file does not show that the Plan provided notice that the 
services would not be covered. Under Medicare rules, this means the services is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the services (CPT 90912) you received on January 2, 
2020.  
 
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: 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 
patient is medically stable after a pulmonary embolism with no evidence of complex medical issues that require 
monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab 
nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of 
need for an intensive therapy program with or therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. The enrollee's rehab needs can be met at an alternate, low 
intensity level setting. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thirty (30) minutes of psychotherapy (90832) provided on 
May 12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that medically necessary services were rendered in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 thirty (30) minutes of psychotherapy (90832) 
provided on May 12, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF services that 
cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says rules for IRF care 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are 
no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that they do not see that the member needs things that cannot be 
done a lower level of 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for long-term complications of anoxic brain 
injury. The enrollee has pressure sores and is chronically on a ventilator. The enrollee's PEG tube became 
dislodged and had to be converted to an NG tube. There appears to be no expectation of ventilator liberation or 
decannulation. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment and osseous surgery provided on 
May 28, 2020 by an OON provider. 
 
You asked the Plan to pay for the occlusal adjustment and osseous surgery. You say that the $500 benefit you 
had to cover you for the year was not accepted for these services. The Plan denied your request. The Plan says 
the treating provider is OON. The Plan also says that services are only covered when they are rendered by an 
in-network 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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the occlusal 
adjustment and osseous surgery provided on May 28, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the leadless pacemaker (33274) provided on April 21, 2020. 
 
You asked the Plan to pay for the leadless pacemaker (33274). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says per Medicare guidelines, 
leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. In this case, Medicare guidelines say leadless pacemakers are non-
covered when furnished outside of a CMS approved CED study. The file does not show that the enrollee had 
the procedure performed under a CMS approved CED study. Based on this information, we decided that 
 
Medicare rules for coverage of the leadless pacemaker (33274) have not been met. Therefore, we decided that 
the Plan does not have to pay for the leadless pacemaker (33274) provided on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3346). 
 
You asked the Plan to pre-approve the retreatment of previous root canal therapy. You say that you had a root 
canal done over 30 years ago, and you need this service done. The Plan denied your request. The Plan says this 
service is not covered under your benefit package. 
 
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 pre-approve a 
retreatment of previous root canal therapy (D3346).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the thorax (71270) and of the abdomen and pelvis 
(74177). 
 
You asked the Plan to pre-approve CT scans of the thorax, abdomen, and pelvis. You say that CT scans are 
medically necessary. The Plan denied your request. The Plan says that rules for CT scans have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 CT scans of the thorax, abdomen, and 
pelvis. Our reviewer says that CT scans are medically necessary. Our physician reviewer found that this 
enrollee with unexplained weight loss has had a renal ultrasound. A CT scan will provide useful information. 
CT scans are indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the thorax, abdomen, and pelvis have been met. Therefore, we 
decided that the Plan has to pre-approve a CT scan of the thorax (71270) and of the abdomen and pelvis 
(74177).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (A4450, A6197, A6253, A6402, A6446) 
provided March 18, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for medical supplies (A4450, A6197, A6253, A6402, A6446) provided March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crown (D3750) for tooth # 18 and the pontic 
(D6240) for tooth # 19. 
 
You asked the Plan to pre-approve the dental services. You say that even with the approval of the crown for 
tooth # 20, you still cannot get it done. You say that there is no tooth next to it for the crown to connect to. You 
say that you need a bridge for the crown to connect to. You also say that the bridge in your mouth is half 
broken and you do not want it to come out. The Plan denied your request. The Plan says crowns are covered 
once per tooth every 5 years. The Plan says that the frequency limit has been reached for these services. 
 
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 and crowns are a covered service, the 
frequency limit of once per tooth every 5 plan years has been reached. The record shows you received crowns 
for these teeth on April 17, 2018. Therefore, we decided that the Plan does not have to pre-approve the retainer 
crown (D3750) for tooth # 18 and the pontic (D6240) for tooth # 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the vision services (92014 and 92250). You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does 
not have out-of-network benefits. 
 
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 medical services provided on January 17, 2020 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 7, 2020, to 
June 5, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services 
rendered during this time are considered custodial, as this is care provided in a facility setting when the enrollee 
did not need skilled medical care or skilled nursing care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from May 7, 2020, to June 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided on March 10, 
2020. 
 
You asked the Plan to pay for out of network care. You say that these services should be covered by the Plan. 
The Plan denied your request. The Plan says you 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network mental health care provided on March 10, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvelaparoscopic sleeve gastrectomy (43775).You asked the Plan to pre-approvelaparoscopic sleeve gastrectomy. You say that that currently the enrollee's bariatric surgeon, along with her primary care physician believe that the enrollee will significantly benefit from thelaparoscopic sleeve gastrectomy.The Plan denied your request. The Plan says that the enrollee does not met the Medicare criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 laparoscopic sleeve gastrectomy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case has met the coveragecriteria for laparoscopic sleeve gastrectomy. The documentation supports that the enrollee has a body-mass index (BMI) of at least 35 kg/m2, has at least one co-morbidity related to obesity, and has been previously unsuccessful with medical treatment for obesity.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laparoscopic sleeve gastrectomy have been met.Therefore, we decided that the Plan has to pre-approvelaparoscopic sleeve gastrectomy (43775).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 toopen the case again, we will send you a letter.