Persius/hicric huggingface dataset:
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 need IRF care to return home to at your prior 
level of independence. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for progressive lenses (V2781) provided on August 9, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that your provided did not tell them you had any of the 
special conditions the Plan provider Manual lists are required for progressive lenses (V2781). 
 
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 up to $500 for eyeglasses (frames and lenses) every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they will pay for the following services: up to 
$500 for eyeglasses (frames and lenses) every two years. The record shows that the contract (the EOC) does 
not specify any conditions regarding the coverage of progressive lenses. Based on this information, we decided 
that the Plan's rules for coverage of progressive lenses (V2781) have been met. Therefore, we decided that the 
Plan has to pay for progressive lenses (V2781) provided on August 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 72125-26 and 71045-26 billed for date of service July 
12, 2022. 
 
You asked the Plan to pay for codes 72125-26 and 71045-26. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for codes 72125-26 and 71045-26 have not been met. Therefore, we decided that the Plan does not have to pay for codes 72125-26 and 71045-26 billed for date 
of service July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), and 
polycarbonate lenses (V2784) provided on July 28, 2022. 
 You asked the Plan to pay for frames (V2020), progressive lenses (V2781), and polycarbonate lenses (V2784). 
You say that since your recent cataract surgery on both eyes, your eyes are much more sensitive to sunlight. 
You also say that for this reason, you purchased one pair of regular bifocals and as bifocal glasses. The Plan 
denied your request. The Plan says based on the member's 2022 Evidence of Coverage, the member is 
responsible for any amount over the $200 retail price. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when a $200 benefit toward the purchase and fitting of eyeglasses and 
pair of lenses (1 per calendar year). The Plan rules also say you pay in-network any amount over the $200 retail 
price. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $200 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses (1 per calendar year). The Plan rules also say you pay in-network any 
amount over the $200 retail price. Based on this information, we decided that the Plan's rules for coverage of 
frames (V2020), progressive lenses (V2781), and polycarbonate lenses (V2784) have not been met. Therefore, 
we decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), and 
polycarbonate lenses (V2784) provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visits (99203, 99212), the acupuncture treatments (97813, 
97814), and the infrared therapy (97026) provided on December 21, 2021 and December 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we requested the Evidence of Coverage (EOC) contract from the 
Plan for the year 2021 in which the services were provided. However, we did not receive this information. We 
are unable to determine your allowable benefits as we did not receive the correct Plan contract. The Plan has 
not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to 
pay for the office visits (99203, 99212), the acupuncture treatments (97813, 97814), and the infrared therapy 
(97026) provided on December 21, 2021 and December 23, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty to allow access for 
restorative procedure (D4212) for tooth number 9. 
 
You asked the Plan to pre-approve gingivectomy or gingivoplasty to allow access for restorative procedure 
(D4212) for tooth number 9. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this procedure is not covered under the member's Plan per the EOC. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) for tooth number 9.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you did not call 911, did not receive 
treatment or used the transportation service to the hospital. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 10, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these  lab services were medically necessary. 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, for 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 May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injection, vedolizumab provided on May 26, 
2022. 
 
You asked the Plan to waive the cost share for injection, vedolizumab. You say that you believe that you have 
met your out-of-pocket maximum. The Plan denied your request. The Plan says this cost sharing was charged 
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 $712.54 
out-of-pocket maximum for in-network maximum out-of-pocket. You have $2,882.42 out of $4,100 out-of-
pocket maximum therefore you have not met your out-of-pocket maximum.  
 
You have been asked to pay $712.54 out-of-pocket maximum for injection, vedolizumab. This item/service 
falls within the in-network maximum out-of-pocket 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 
cost share for injection, vedolizumab provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951). 
 
You asked the Plan to pre-approve sinus augmentation. You say that this service is medically necessary. The 
Plan denied your request. The Plan says that sinus augmentation (D7951) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 sinus 
augmentation (D7951).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed or Venofer is required before alternatives 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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective for this 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 47361) provided to the 
enrollee on June 27, 2022. 
 
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 denied code cannot be verified. 
 
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 47361 is "Management of liver hemorrhage; exploration 
of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes 
procedures performed in same anatomical area, and therefore would not be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 47361) provided to the enrollee on June 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on August 20, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that an explanation of benefits from the 
enrollee's primary insurance carrier is needed before this claim can be considered for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the anesthesia services provided on August 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says it will continue to 
cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for 
transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical circumstances 
change such that LTACH may be reconsidered. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a SPRINT peripheral nerve 
stimulator. 
 
You asked the Plan to pre-approve the implantation of a SPRINT peripheral nerve stimulator. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's 
condition. 
 
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 implantation of a SPRINT 
peripheral nerve stimulator. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the use of a SPRINT peripheral nerve 
stimulator is experimental for Complex Regional Pain Syndrome involving the suprascapular nerve. 
 
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 implantation of a SPRINT peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a SPRINT peripheral 
nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a pulp vitality test 
(D0460), and does not have to waive the cost share for a root canal on tooth #27 (D3310) provided on August 
27, 2022. 
 
You asked the Plan to pay for an evaluation and pulp test. You also asked the Plan to waive the cost share for a 
root canal. You say that you were shocked when you had to pay up front when you have insurance. The Plan 
denied your request. The Plan says this cost sharing was charged correctly for a root canal. The Plan also says 
that a limited oral evaluation and a pulp vitality test are not covered by your dental 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 have a $50 dental 
deductible which applies to a root canal. The contract also says that you must pay 50% coinsurance for a root 
canal (D3310) after the deductible is met. 
 
Your dental deductible was not met prior to receiving a root canal on August 27, 2022. The new allowed 
amount after the deductible was satisfied is $245 ($295 original allowed amount - $50 deductible = $245 new 
allowed amount). You have been asked to pay $122.50, which is 50% coinsurance of the allowed amount for a 
root canal ($245 new allowed amount x 50% coinsurance = $122.50). This item/service falls within the dental 
services 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.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a limited oral evaluation and a pulp 
vitality test are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140), a pulp vitality test (D0460), and does not have to waive the cost 
share for a root canal on tooth #27 (D3310) provided on August 27, 2022.