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

 
We decided that the Plan does not have to pay for eyeglass lenses you purchased on January 28, 2022. 
 
You asked the Plan to pay for the eyeglass lenses. You say that you cannot see well without your glasses, so 
you have always had a second pair of eyeglasses made.  You said that you had a major change in your eyeglass 
prescription and you were told that these lenses were approved The Plan denied your request. The Plan says 
you were not eligible for another set of lenses on this date of service. Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine 
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers lenses once every two years.  In this case, you had already received a set of covered 
lenses on December 20, 2021, so you were not eligible for another set on January 28, 2022. This restriction 
applies regardless of necessity or change in your prescription. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglass lenses have not been met. Therefore, we decided that the Plan does not 
have to pay for eyeglass lenses you purchased on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
lumbar spine provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were informed the service would 
be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 CT, MRI, MRA, and SPECT scans.  
 
You have been asked to pay $179.09, which is less than the $200 copayment for the CT scan. The CT scan falls 
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 a computed tomography (CT) scan of the lumbar spine provided on 
December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 10, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should only be responsible for 
the $25 office copayment that you already paid. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $20 
copayment for an ultrasound. The contract also says a separate physician office copay may apply if other 
services are rendered at the time of the visit. 
 
The record shows this claim was approved, and you have an additional cost sharing amount. You have been 
asked to pay a $10 copayment for an ultrasound. An ultrasound falls 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 February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from 
November 30, 2021, to December 23, 2021. 
 
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 there is a missing Health Insurance Prospective Payment System (HIPPS)  rate 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. 
 
We find that the denied home health services are not supported in the medical records. The case file does not 
show a valid HIPPS code for these services. 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 home 
health services provided to the enrollee from November 30, 2021, to December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 1, heavy-duty, power scooter, patient weight 
capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve the heavy-duty scooter. You say that your current scooter is over 5 years 
old, is unsafe for you to use and can no longer be repaired. The Plan denied your request. The Plan says the 
enrollee meets the criteria for a standard scooter and does not meet the criteria for the heavy-duty scooter 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
In the case, the requested group 1 heavy duty scooter is only covered for a beneficiary weighing 301-450. The 
records show that the enrollee's weight is 257 pounds. We looked at the file, and Medicare rules.  The enrollee 
does not meet the weight requirement for the requested heavy-duty power scooter. Based on this information, 
we decided that Medicare rules for coverage of the heavy-duty scooter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the group 1, heavy-duty, power scooter, patient weight 
capacity 301 to 450 pounds (K0801).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447-59-RT billed for date of service 
December 2, 2021. 
 
You asked the Plan to pay for procedure code 64447-59-RT. You say that this claim was billed correctly. The 
Plan denied your request. The Plan says the records do not support the billing of code 64447-59-RT for two reasons. First, the records didn't include that injections of the femoral nerve were performed. Second, the -59 
modifier wasn't supported and this code is considered part of code 01402. There is a more appropriate code 
(64450) that should have been billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 64447-59-RT. Our reviewer 
says that code 644447-59-RT is not supported in the medical record. Our physician reviewer found the 
anesthesia report documents "Spinal block resulted; (edited); last update 12/2/21 12:10 status: Edited result - 
FINAL".  The documentation does not support criteria for post op pain management, and therefore cannot be 
verified as a separate procedure, and not part of the operative anesthesia performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64447-59-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64447-59-RT billed for date of service December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraoperative electrocorticography. 
 
You asked the Plan to pre-approve an intraoperative electrocorticography. You say that your pain is on level 8 
and you need the requested procedure. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for coverage. 
 
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 an intraoperative electrocorticography. 
Our reviewer says that an intraoperative electrocorticography is not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding any 
significant medical history (including seizure activity) to support this requested test. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intraoperative electrocorticography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intraoperative electrocorticography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 5, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you are questioning why your cost 
share is greater than the billed amount by the provider. The Plan denied your request. The Plan says the 
deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to an office visit. Covered services 
include consultation, diagnosis, and treatment by a specialist.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible which applies to an office visit. This cost sharing is a 
contractual obligation that had not been met at the time an office visit was received on January 5, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on 
January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on  November 17, 2021, and 
November 22, 2021. 
 
You asked the Plan to pay for acupuncture. You say that the enrollee has coverage for acupuncture. The Plan 
denied your request. The Plan says a licensed acupuncturist is a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type. Therefore, we decided that the Plan does not have to pay for acupuncture provided on  November 17, 
2021, and November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
23, 2021. 
 
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 ordering a multi-drug panel of definitive (confirmation) urine drug tests that are not used in the 
management of the enrollee 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was sufficient information to manage the enrollee without the definitive testing. The review 
has determined that the enrollee did not meet the criteria for this testing. The enrollee did not need all the tests 
done. 
 
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 pay for drug testing services provided to the enrollee on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip nerve block. 
 
You asked the Plan to pre-approve a nerve block. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that nerve blockades are covered only for the indications 
established in the applicable LCD. 
 
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 a nerve block. Our reviewer says that 
the requested nerve block is not medically reasonable and necessary. Our physician reviewer found that this 
procedure is experimental for the treatment of the pain from hip osteoarthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hip nerve block.
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 enrollee fully meets criteria for IRF. The Plan 
denied your request. The Plan says the enrollee does not meet criteria and could be treated in a lower level of 
care facility such as a skilled nursing facility. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) or pay more for 
eye exam (92004) provided on December 14, 2021. 
 
You asked the Plan to pay for the determination of refractive state and to pay more for the eye exam. You say 
that you went to the desk, told them which plan you had, and gave them your insurance card. You also say that 
you told them you needed an exam to get your glasses. The Plan denied your request. The Plan says the treating 
provider is OON, and you do not have OON benefits with your vision plan. 
 
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. Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts, and 
you are responsible for a $45 copayment for specialist office visits. 
 
 
 We looked at the file and the Plan's rules. You were correctly charged a $45 copayment for the eye exam for 
your glasses. You were also correctly denied coverage for the refraction because it would only be covered 
when rendered by a Plan approved vision provider. Based on this information, we decided that the Plan's rules 
for coverage of the eye exam and determination of refractive state have not been met. Therefore, we decided 
that the Plan does not have to pay for the determination of refractive state (92015) or pay more for eye exam 
(92004) provided on December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on January 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for radiology services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the member's plan excludes coverage for this OON 
service. 
 
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 radiology services 
provided on January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a denosumab (Prolia) injection and a 
specialist office visit provided on February 1, 2022. 
 
You asked the Plan to reduce the cost share for an injection and specialist office visit. You say that Prolia is a 
tier 3 drug and should only be charged $150. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 20% 
coinsurance for in-network Part B drugs. The Plan contract says that enrollees must pay a $35 copayment for 
an in-network specialist office visit. 
 
 The record shows the injection was done in the providers office. Therefore, the injection is covered through 
the Medicare Part B drug benefit. You have been asked to pay $254.28, which is 20% coinsurance of the 
allowed amount for an injection ($1,271.40 allowed amount x 20% coinsurance = $254.28). An injection falls 
within Medicare Part B Prescription Drugs benefit category.  
 
You have been asked to pay the allowed amount of $11.89, which is less than the $35 copayment for a 
specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including 
Doctors Office Visits benefit category. You have been asked to pay a total of $266.17 ($254.28 coinsurance + 
$11.89 copayment = $266.17). 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 reduce the cost share for a denosumab (Prolia) 
injection and a specialist office visit provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle brace (code L1902) provided on April 23, 2021. 
 
You asked the Plan to pay for the ankle brace. You say that you have provided evidence of delivery of this item 
and this item was medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not include sufficient information regarding the supplied item. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must supply a Proof of Delivery for 
items they ship to patients. The Proof of Delivery documents must include the following elements: the 
beneficiary's name, the delivery address, the delivery service's package identification number, a description of 
the items being delivered (such as a narrative description, a code, or a brand/item number), the quantity 
delivered, the date delivered, and evidence of delivery. 
 
In this case, the only Proof of Delivery document you provided is the United Parcel Service proof of delivery 
document.  This document is missing the beneficiary's name, address, and a description of the item being 
delivered.  All of these are required elements for Proof of Delivery, so the documentation you submitted is not 
sufficient to meet Medicare requirements.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ankle brace have not been met. Therefore, we decided that the Plan does not have to pay for the 
ankle brace (code L1902) provided on April 23, 2021.