Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided from October 15, 
2021, to October 21, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the enrollee has been receiving this treatment for 
chronic obstructive pulmonary disease (COPD) as recommended by his physician. These services were 
necessary and have been paid in the past. The Plan denied your request. The Plan says procedure code 90832 
(psychotherapy, 30 minutes) was billed for October 15, 2021, and October 21, 2021, with a primary diagnosis 
of chronic obstructive pulmonary disease, unspecified (J44.9) and a secondary diagnosis of illness, unspecified 
(R69). It is inappropriate to bill medical diagnosis codes for behavioral health procedure codes. The diagnoses 
billed with this service are inappropriate for the service provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that there are specific diagnosis codes which support the medical necessity of CPT code 90832. 
 We find that CPT code 90832 is not supported in the medical record. Specifically, the diagnosis codes billed on 
this claim are not included on the list of appropriate diagnosis codes which support the medical necessity of 
CPT code 90832. Based on this information, we decided that Medicare rules for coverage of psychotherapy 
have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services 
(90832) provided from October 15, 2021, to October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings and sales tax identified with code 
A6530, A6533 and A6533 that were issued on September 27, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these items are not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530, 
A6533 and A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings and sales tax identified with code A6530, A6533 and A6533 that were issued on September 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on 
November 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the facility requested this provider 
be called in to see the patient as an attending provider in an outpatient capacity. You also say that there is a 
medical necessity pre-established with the patient and the facility, for this provider to provide services to the 
patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan, and the referral was not authorized by the primary care physician (PCP). The Plan also says that they 
have also determined that these services are not urgent or emergent, nor were they 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 a domiciliary or rest home visit (99337) provided 
on November 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection procedure you had at an 
ambulatory surgery center on November 10, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you should not 
have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery and services at an ambulatory surgical center.  
 
You have been asked to pay a $200 copayment for the outpatient surgery services. The outpatient surgery 
services falls within the outpatient surgery and services at an ambulatory surgical center benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the injection procedure you had at an ambulatory surgery 
center on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on June 10, 2021, and June 11, 2021 
 
You asked the Plan to pay for the eyeglasses. You say that you need all three pairs of eyeglasses so you can use 
the computer, see normally, and so you can see when you drive in the bright sunlight. The Plan denied your 
request. The Plan says the service is a covered benefit, but the enrollee has exceeded limits set in the subscriber 
agreement. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. We looked at the file and the Plan's rules. The file shows that the Plan paid for one pair of eyeglasses provided 
on June 12, 2021.  Based on this information, we decided that the Plan's rules for coverage of the eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on 
June 10, 2021, and June 11, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches and 
this is a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because Vertiflex is experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for the enrollee's condition. There is no compelling rationale or extenuating circumstance presented 
to support the 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the portable, group 1 power wheelchair 
(K0813) and the sales tax (S9999) rendered by the out-of-network (OON) provider on August 18, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the wheelchair was rendered by an out of 
network provider, without prior authorization. 
 
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 issue reimbursement 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 had network providers available 
who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to issue reimbursement. Therefore, we decided that the Plan 
does not have to issue reimbursement for the portable, group 1 power wheelchair (K0813) and the sales tax 
(S9999) rendered by the out-of-network (OON) provider on August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta 0.024% solution. 
 
You asked the Plan to pre-approve the Vyzulta. You say that Vyzulta is medically necessary. The Plan denied 
your request. The Plan says Vyzulta is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta 0.024% solution.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Gel-One and Synvisc 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiothoracic surgery office visit (99205, 99214) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the cardiothoracic surgery office visit. You say that these services are 
medically necessary. The Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
cardiothoracic surgery office visit (99205, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on September 18, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the procedure code at issue is inclusive to another billed code. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) 
provided on September 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on October 13, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says the member 
was enrolled in hospice. 
 
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 on October 10, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on October 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you 
received on March 24, 2021. 
 
You asked the Plan to waive the copayment for the ER services. You say that you have two insurance 
companies and you went to an in-network hospital, so you should not have any out-of-pocket expenses. You 
believe that if you go in-network, this should be covered 100%. The Plan denied your request. The Plan says 
you were charged this copayment correctly.  The Plan says that it is only charging you $74.78 for this ER visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
 You have been asked to pay a $90 copayment for the ER services. This cost sharing applies regardless of what 
you may have paid in the past for similar services. There is no provision in your contract to cover emergency 
room services at $0 copayment. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) 
services you received on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, & require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 the documentation does not support that you require at least 3 hours a day /5 days a 
week, or 15 hours over 7 consecutive days, of therapy services.  The documentation does not support 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not need 
skilled nursing or therapy services on a daily basis. 
 
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 services. Our physician reviewer 
found that you were admitted to the acute hospital for a mitral valve repair. You do not require the services of a 
skilled professional nurse to provide treatment. Although you may benefit from continued skilled therapy 
services, it is not medically necessary to provide skilled therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had cellulitis, abscess, or ulceration. 
 
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 requested services. Our physician 
reviewer found that the enrollee previously underwent open gastric bypass in 2002. She now has excessive and 
redundant skin and subcutaneous tissue. She was evaluated for body contouring. She reported stable weight, 
rashes treated with nystatin powder, interference with ambulation, skin pulling and tears. Examination 
documented diffuse severe skin laxity and mild pink moist rash beneath the right pannus.  
 The documentation does not support that she has recurrent rash or nonhealing ulcers that have not responded to 
conventional treatment. Therefore, the requested services are not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy.
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 would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the IRF care. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation 
does not support that you require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of 
therapy services. It is not clear 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.