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

 
We decided that the Plan does not have to pre-approve four additional transportation trips for the 2020 calendar 
year. 
 
You asked the Plan to pre-approve the additional trips. You say that you need four more trips for the year to 
allow you to get to appointments related to bariatric surgery. This cannot be put off any longer since you 
cannot have knee surgery until after the bariatric surgery. The Plan denied your request. The Plan says your 
routine transportation benefit is limited to 24 trips per year. No additional trips are covered under this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 
 
 
 
 
 
 
 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will have exhausted the Plan maximum benefit for coverage of routine transportation after your 24th 
trip. Therefore, we decided that the Plan does not have to pre-approve four additional transportation trips for 
the 2020 calendar year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the eyeglasses following cataract surgery 
purchased on June 16, 2020, from an out-of-network (OON) provider. 
 
You asked the Plan to waive the cost share for the eyeglasses following cataract surgery. You say that you were 
not aware you would be responsible for the deductible for purchases made OON. The Plan denied your request. 
The Plan says the cost share has processed correctly for this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible for vision care when received from an OON 
provider.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category vision care. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for 
vision care received from an OON provider. This cost sharing is a contractual obligation that had not been met 
at the time the eyeglasses following cataract surgery was received on June 16, 2020. Therefore, we decided that 
the Plan does not have to waive the cost share for the eyeglasses following cataract surgery purchased on June 
16, 2020, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on March 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99239 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of hospital discharge services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on March 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (87491, 87591) provided on April 2, 2020. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing 
(87491, 87591) provided on April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show its 
safety and efficacy. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending 
physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing aids (V5299) provided on January 
27, 2020. 
 
You asked the Plan to waive the copayment for hearing aids. You say that the item should be covered. The Plan 
denied your request. The Plan says you are responsible for your share of cost such as deductible, coinsurance or 
copayment when you received covered service items. 
 
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 up to 2 aids per year, 1 aid per ear, with a $1,150 copay for premier level hearing aids.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aids have not been met. Specifically, premier level hearing aids have a 
$1,150 copay. Therefore, we decided that the Plan does not have to waive the copayment for hearing aids 
(V5299) provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the complete upper denture (D5110), the 
panoramic x-ray (D0330), and the unspecified preventive service (D1999) provided on July 21, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that you were never advised that the 
services would not be covered. The Plan denied your request. The Plan says there is a $1,000 allowance for 
dental services. The Plan says that the allowance has been exhausted in the processing of this claim. 
 
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 $1,000 dental allowance has been 
exceeded. 
CPT Code Allowed Amount Plan Paid Your Responsibility 
D0140 $66 $66 $0 
D5110 $1,020 $934 $86 
D0330 $97 $0 $97 
D1999 $10 $0 $10 
TOTAL:  $1,000 $193 
Therefore, we decided that the Plan does not have to pay the full amount for the complete upper denture 
(D5110), the panoramic x-ray (D0330), and the unspecified preventive service (D1999) provided on July 21, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department visit for the 
evaluation and management of a patient (99285) provided on June 4, 2020. 
 
You asked the Plan to waive the copayment for emergency department visit. You say that you do not know 
why this is being called an observation when the enrollee was clearly admitted. The Plan denied your request. 
The Plan says this claim processed and the correct copayment was applied per the plan benefits. 
 
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 $50 for 
each Medicare covered emergency room visit.  
 
You have been asked to pay $50 for the emergency department visit. The emergency department visit falls 
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 emergency 
department visit for the evaluation and management of a patient (99285) provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox 200-unit injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider has not demonstrated why it is medically necessary to make an exception. 
 
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 the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found Botox 200-unit 
injection is requested for prevention of migraine headaches. It is noted that the request for Botox is a new start, 
the enrollee has failed Topiramate in the past (2010), and that she had good results with Botox about 6 years 
 
 
ago. The plan requires a trial of Propranolol, Timolol, or Metoprolol before they will cover Botox. There is no 
documentation that the enrollee has previously tried one of the noted beta blockers, or that beta-blockers are 
contraindicated or otherwise inappropriate for this enrollee. In summary, neither step therapy nor step therapy 
exception criteria are met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Botox 200-unit injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 64492 and 64491 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64492 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 
procedure). The definition of code 64491 is injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; second level (List separately in addition to code for primary procedure). 
 
We find that CPT codes 64492 and 64491 are not supported in the medical record. Specifically, there is no 
documentation of a cervical or thoracic injection with image guidance at the third and any additional level to 
support code 64492. There is no documentation of a cervical or thoracic injection with image guidance at the 
second level to support code 64491. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the injection 
services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 13, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 August 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided May 26, 2020 to 
June 10, 2020. 
 
You asked the Plan to pay for the skilled nursing care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was submitted with an invalid provider taxonomy. 
 
The Plan must follow Medicare rules. Medicare rules say that Registered Nurses are not eligible for payment.  
 
We looked at the file and Medicare rules. The rendering taxonomy submitted on the claims was 
163WW0000X, Registered Nurse Wound Care. Based on this information, we decided that Medicare rules for 
coverage of the skilled nursing care have not been met. Therefore, we decided that the Plan does not have to 
pay for skilled nursing facility services provided May 26, 2020 to June 10, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 enrollee was admitted for pneumonia. Medical problems 
are stable. 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, in 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 this 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 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 USB charger, Seat Lift Mechanism, active reach, LED 
light kit, expandable controller, harness and electronic connection. 
 
You asked the Plan to pre-approve the accessories. You say that you would like reconsideration because these 
items are medically necessary. The Plan denied your request. The Plan says the USB charger, seat lift, active 
reach and LED light kit do not service a medical purpose and there is no medical need for the upgraded 
electronics. 

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 items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found The power seat elevation feature (E2300) is not primarily medical in nature and therefore not medically 
necessary. The K0108, 20 Active Reach is to be used with a power adjustable seat height. As the  power seat 
elevation feature (E2300) is not medically necessary the 20 Active Reach K0108 is not medically necessary. 
 
The expandable harness (E2313), the (E2311) electronic connection, and the (E2377) expandable controller are 
not medically necessary. The documentation does not reveal that the member needs an expandable controller to 
operate other types of proportional input devices, non-proportional input devices or to operate 3 or more 
powered seating actuators through the drive control. The documentation does not reveal the member needs the 
expandable controller to operate a separate display, other electronic devices, or for an attendant control. The 
member has sufficient strength in the upper extremities and functional ability to operate any power options 
through their own individual switches. 
 
Per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested K0108 USB Charger 
and K0108 Light Kit are not primarily medical in nature and are not reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a USB charger, Seat Lift Mechanism, active reach, LED light kit, expandable controller, 
harness and electronic connection.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 enrollee was admitted for fractures of the tibia and 
humerus after a fall. These were treated non surgically. Medical problems are stable. 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, in 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 this 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 acute inpatient rehabilitation facility (IRF) admission and services.