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

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the yoga classes purchased on December 31, 2021. 
 
You asked the Plan to pay for the yoga classes. You say that you submitted an itemized bill which shows the 
yoga classes were paid for. The Plan denied your request. The Plan says that it was determined that the yoga 
classes you have prepaid for on December 31, 2021, would have taken place in 2022. The Plan also says while 
it is not eligible for reimbursement under your 2021 Wellness Allowance benefit, it would be eligible under 
your 2022 Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $250 
per calendar year towards your cost for membership in a qualified health club or fitness facility, covered 
instructional fitness classes, and participation in wellness programs. 
 
The Plans rules for coverage of gym benefits have been met because while the Evidence of Coverage states 
the Plan will cover $250 per calendar year under your Wellness Allowance, it does not clearly state that the 
membership you pay for must be for the specific Plan year. The record shows that you purchased yoga classes 
in advance on December 31, 2021, to be used during the 2022 plan year. You reasonably believed this purchase 
would be covered because the contract does not clearly state the membership must be both purchased and used 
during the 2021 plan year. Therefore, we decided that the Plan has to pay for the yoga classes purchased on 
December 31, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG), continuous recording (95718) 
provided on March 26, 2022. 
 
You asked the Plan to pay for the ambulatory EEG. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage of this service are not met; there is no 
documentation to show that the enrollee has had a resting EEG before this diagnostic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulatory EEG should always be preceded 
by a resting EEG.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee has had a resting EEG 
before the EEG in question. Based on this information, we decided that Medicare rules for coverage of the 
ambulatory EEG have not been met. Therefore, we decided that the Plan does not have to pay for 
electroencephalogram (EEG), continuous recording (95718) provided on March 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 8, 2021. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says there is no 
documentation of an individualized treatment plan stating the type, amount, frequency, and duration of the 
services to be furnished and indicating the diagnoses and anticipated goals. There is no evidence showing that 
the patient continues to show improvement in accordance with his/her individualized treatment plan 
 
The Plan follows Medicare rules.  
 
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 psychotherapy. Our reviewer says that 
the psychotherapy is not medically necessary. Our physician reviewer found that based on review the records 
provided, the enrollee was found to be alert, oriented to person, place and time. She was found to be euthymic 
and stable while appropriate with good long-term memory appear short-term memory. The enrollee did not 
have any suicidal or homicidal thoughts. The intervention used was exploration of emotions, supported 
reflection and symptom management. On review the records provided and utilizing LCD L33632 this enrollee 
does not meet the criteria as noted including required documentation. 
 
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 psychotherapy have not been met. Therefore, we decided that the Plan does 
not have to pay for psychotherapy provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and removal of 
sinus tarsi implant (0510) provided on February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit and removal of sinus tarsi implant. You say 
that the services were medically necessary. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 hospital outpatient clinic visit (G0463) and 
removal of sinus tarsi implant (0510) provided on February 23, 2022, by an out-of-network (OON) provider.
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 you are appealing with supporting 
documents. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
care in a LTACH. The Plan also says that the enrollee is receiving appropriate in-patient acute care and does 
not require transfer to LTACH. 
 
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. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where care is currently being received.  
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve blocks provided on March 18, 2022. 
 
You asked the Plan to pay for the genicular nerve blocks. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided were 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 pay for the genicular nerve blocks. 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 left knee pain due to osteoarthritis. Genicular nerve blocks and 
genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the 
treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; 
osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore, the enrollee 
did not meet criteria for the services rendered. 
 
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 genicular nerve blocks have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve blocks provided on March 18, 2022.
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 you had bypass heart surgery and the plan turned 
down therapy. You say that you really need this. The Plan denied your request. The Plan says we determined 
that based on Medicare guidelines the inpatient rehabilitation facility services requested you do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 you were admitted for coronary artery bypass grafting. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While you have a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. 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 Vertiflex Superion device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety 
and efficacy of the device. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is medically reasonable and necessary. Our physician reviewer found that the enrollee does 
not qualify for SNF coverage. In this case, the enrollee does not have documented skilled nursing needs. 
Furthermore, the enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the lens (V2782). We decided that the Plan does not have to pay for the 
U-V lens (V2755), anti-reflective coating (V2750), and photochromatic tint (V2744).  
 You asked the Plan to pay for the lens (V2782), U-V lens (V2755), anti-reflective coating (V2750), and 
photochromatic tint (V2744) provided on March 26, 2022. You say that you followed the document for 
coverage, and the payment cannot be denied. The Plan says that these services are not covered benefits. 
 
We decided that the Plan has to pay for the lens (V2782).  
 
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 offers a $350 plan coverage limit for eyeglasses, frames, lenses, or contacts every two (2) 
years. 
 
We looked at the file and the Plan's rules. The provided information does not show that you have exhausted the 
$350 coverage limit for eyewear. The lens (V2782) service at appeal is the lens thickness, and is coverable 
under the coverage limit. Based on this information, we decided that the Plan's rules for coverage of the lens 
(V2782) have been met. Therefore, we decided that the Plan has to pay for the lens (V2782).  
 
We also decided that the Plan does not have to pay for the U-V lens (V2755), anti-reflective coating 
(V2750), and photochromatic tint (V2744). 
 
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. 
 
We looked at the file and the Plan's rules. The contract clearly states that enhancements are not covered through 
the allowance but may be purchased at an additional cost. Based on this information, we decided that the Plan's 
rules for coverage of the U-V lens (V2755), anti-reflective coating (V2750), and photochromatic tint (V2744) 
have not been met. Therefore, we decided that the Plan does not have to pay for the U-V lens (V2755), anti-
reflective coating (V2750), and photochromatic tint (V2744). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the hearing aids (V5251, V5257) 
purchased on January 28, 2022. 
 
You asked the Plan to issue additional reimbursement for these items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exceeded the allowable benefit for the hearing aids purchased in this case. 
 
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 plans coverage rules apply in this case.  
 
We looked at this file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of these items have not been met. Specifically, the Plan rules state that hearing aids will be 
covered in the amount of $500 every 3 calendar years. The Plan issued reimbursement to you in the amount of 
$500 on February 17, 2022. Therefore, you have exhausted the allowable benefit for these items. Therefore, we 
decided that the Plan does not have to issue additional reimbursement for the hearing aids (V5251, V5257) 
purchased on January 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on March 16, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the psychotherapy was medically necessary. The 
Plan denied your request. The Plan says that there is no evidence showing that the patient continues to show 
improvement and no documentation of a reasonable expectation of improvement, in accordance with his/her 
individualized treatment plan. 
 
The Plan follows Medicare rules.  
 
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 psychotherapy. Our reviewer says that the 
psychotherapy was medically necessary. Our physician reviewer found that this enrollee suffered from Major 
Depressive Disorder, Recurrent, Moderate, Generalized Anxiety Disorder and Insomnia Due to Other Mental 
Disorder. Based on review the records provided, the enrollee appeared to have issues around depression, 
nervousness and anxiety which appeared improved with therapy. The enrollee was treated under individualized 
treatment plan. Based on review the records provided and utilizing LCD L33252 this enrollee does meet the criteria for therapy 
in the nursing facility as the enrollee was treated under an individualized treatment plan with goals.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychotherapy have been met. Therefore, we decided that the Plan has to pay 
for psychotherapy provided on March 16, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip arthroscopy services. 
 
You asked the Plan to pre-approve hip arthroscopy services. You say that the records provided support the need 
for the services in dispute. The Plan denied your request. The Plan says the enrollee has no signs or evidence of 
instability, fracture, or tears. The Plan says that Bursitis is not a condition deemed medically necessary for a hip 
arthroscopy. 
 
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 hip arthroscopy services. Our reviewer 
says that hip arthroscopy services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures. Moreover, there are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hip arthroscopy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hip arthroscopy services.