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

 
We decided that the Plan does not have to pay for an office visit and an interrogation device evaluation 
provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and an interrogation device evaluation. You say that this treatment 
was medically necessary for the enrollee. You also say that this treatment was time sensitive. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan. The Plan says 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 an office visit and an interrogation device 
evaluation provided on January 19, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
28, 2021, to January 26, 2022. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says the enrollee has no documented skilled therapy needs. 
 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 pay for SNF care. Our reviewer says that skilled 
nursing facility (SNF) care is not medically necessary and reasonable. Our physician reviewer found that the 
enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 28, 2021, to January 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
August 4, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the physician is the 
one who ordered the ambulance, and you should not be held liable for it. The Plan denied your request. The 
Plan says the proper copayment was applied for the service that was rendered. 
 
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 $220 
copayment for Medicare-covered ground ambulance services one-way.  
 
  You have been asked to pay a $220 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transportation provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95941) provided on January 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a new HCPCS 
code for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. 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 the 
services (95941) provided on January 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 14, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought this was covered when 
you went in for your mammogram. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $100 
copayment per day for a Medicare-covered ultrasound. 
 
You have been asked to pay $98.58 which is less than the standard $100 copayment for an ultrasound. 
Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 an ultrasound provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the StabiLink placement (CPT code 22612). 
 
You asked the Plan to pre-approve the StabiLink placement. You say that the service is necessary. The Plan 
denied your request. The Plan says interspinous process fusion devices are not proven and medically necessary 
when used as stand-alone lumbar vertebral fusion procedure. 
 
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 StabiLink placement. Our physician 
reviewer found the Food and Drug Administration (FDA) states the StabiLink is not intended for stand-alone 
use. There is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested StabiLink interspinous process fusion device at L5-S1, in this case, is 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 StabiLink placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the StabiLink placement (CPT code 22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (with lateral transverse technique, when performed) (CPT code 22612). 
 
You asked the Plan to pre-approve the services. You say that the procedure will relieve the enrollee of radiating 
pain down her legs due to the multiple levels of spinal canal stenosis. You state the enrollee has tried numerous 
modalities in an attempt to relieve their pain which include, massage, physical therapy, chiropractic, psychiatric 
treatment, in home physician directed exercises and opioids. The Plan denied your request. The Plan says a 
review of the current medical literature indicates that this service is considered experimental and 
investigational as it is not identified as widely used and generally accepted for the proposed use as reported in 
nationally recognized peer-reviewed medical literature published in the English language. The Plan states this 
request is for use of the device as a stand-alone procedure, not as part of a spine surgery. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Food and Drug Administration (FDA) states it is not intended for stand-alone use. There is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
StabiLink MIS Interlaminar Spinal fixation system at L5/S1, in this case, is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral 
transverse technique, when performed) (CPT code 22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the StabiLink placement (Current Procedural 
Terminology (CPT) code 22612). 
 
You asked the Plan to pre-approve the StabiLink placement. You say that the service is necessary. The Plan 
denied your request. The Plan says interspinous process fusion devices are not proven and medically necessary 
when used as stand-alone lumbar vertebral fusion procedure. 
 
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 StabiLink placement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Food and Drug Administration (FDA) states the StabiLink is not intended for 
stand-alone use. There is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested StabiLink device at L5-S1, in this case, is 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 StabiLink placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the StabiLink placement (Current Procedural Terminology (CPT) code 22612).
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 continuation of IRF is necessary for the enrollee. 
You say there are no alternate options for a lower level of care at this time. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for IRF. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an IRF stay. The enrollee does not require continued treatment by multiple therapies, such as physical 
therapy or occupational therapy, in an intensive rehabilitation therapy program. Our physician reviewer says 
the medical record indicates there is a continued need for skilled therapy due to ongoing safety concerns and 
the potential for functional improvement. However, the record does not support that the enrollee currently 
meets the criteria for continued care in an IRF setting.  
 
Furthermore, our reviewer found that the intensive rehabilitation services the enrollee has received did result in 
functional improvement, but the enrollees improvement has since plateaued. Our physician reviewer says the 
enrollee still requires custodial care and would benefit from continued rehabilitation services 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 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: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 10, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you understood this would be covered. You also 
say that you paid the $40 copay, and were not told you would have to pay for anything extra. The Plan denied 
your request. The Plan says refractive procedures are not covered even when done in connection with otherwise 
covered diagnosis or treatment of illness or injury. The Plan also says that the eye exam performed on this date 
of service in question was not a routine eye exam. 
 
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 it is performed during a routine eye exam. 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you were seen for a medical eye examination, 
and not a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polarization (D2762), progressive lenses (V2781), and 
polycarbonate lenses (V2784) provided on December 21, 2021. 
 
You asked the Plan to pay for the polarization, progressive lenses, and polycarbonate lenses. You say that you 
paid $600 for everything and expected to be reimbursed $400. The Plan denied your request. The Plan says the 
maximum allowance for these services was paid. 
 
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 $200 every year for non-Medicare covered eyewear. 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you were reimbursed of $200.16 on February 
14, 2022. Based on this information, we decided that the Plan's rules for coverage of the polarization, 
progressive lenses, and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not 
have to pay for the polarization (D2762), progressive lenses (V2781), and polycarbonate lenses (V2784) 
provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT 
code 27096). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request is deemed not medically reasonable. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (CPT code 27096).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
26, 2021, to November 24, 2021. 
 You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled 
nursing facility level of care. 
 
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 pay for SNF care. Our reviewer says that SNF care 
is not medically necessary. Our physician reviewer found that the enrollee does not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a 
skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 26, 2021, to November 24, 2021.
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 has a specialized device that 
is not accommodated at other facilities. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare guidelines to LTACH admission and the enrollee's needs are currently being met in an acute 
setting. 
 
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 appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be completed at the current facility until a 
lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on April 7, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this service is not 
a covered benefit because it was medical vision check. 
 
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 it is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the eye refraction was performed during a 
medical vision check for Age-related nuclear cataract, bilateral, and not during a routine exam Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the eye refraction provided on April 7, 2022.