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

 
We decided that the Plan does not have to pay for an office or other outpatient visit for evaluation and 
management (99212) provided on November 18, 2021. 
 You asked the Plan to pay for an office or other outpatient visit. You say that the service at issue was billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met because the CPT 
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 99212 is a column II code to column I code 01480; however, 99212 
was billed with a modifier.  
 
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 an office or other outpatient visit. Our reviewer says that the 
billed CPT code does not meet criteria for reimbursement. Our reviewer found that the available documentation 
does not support unrelated procedure from anesthesia nor time spent providing service and therefore the code at 
issue cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit for evaluation and management (99212) 
provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional Percutaneous Tibial Nerve 
Stimulation (PTNS) treatments. 
 
You asked the Plan to pre-approve twelve (12) additional PTNS treatments. You say that additional PTNS 
treatment is medically necessary. The Plan denied your request. The Plan says additional PTNS treatments do 
not meet the Plan's Medical Policy coverage criteria. 
 
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 twelve (12) additional PTNS 
treatments. Our reviewer says that twelve (12) additional PTNS treatments are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the trial was not conducted according to 
guidelines and only one trial is allowed. Therefore, the request is deemed 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 twelve (12) additional PTNS treatments have not been met. Therefore, we 
decided that the Plan does not have to pre-approve twelve (12) additional PTNS treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lenses (V2200) provided on December 31, 2021. 
 
You asked the Plan to pay for the lenses. You say that these lenses were cheaper than those available in-
network and you are unsatisfied with your coverage. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's specified routine vision vendor network. Out-of-
network care is not covered by your 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. The Plan covers these services when they are received from a provider within the specified vendor 
network. 
 
We looked at the file and the Plan's rules. The provider in this case is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglass lenses (V2200) provided on December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you are requesting to go to an out-of-network facility when there are network 
providers available and records do not show a need for skilled nursing facility 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282). 
 
You asked the Plan to pay for the wig. You say that the wig was medically necessary. The Plan denied your 
request. The Plan says this is not a covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76000) provided September 17, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 76000 is not supported in the medical record. Specifically, this service is inclusive to 
the primary procedure, CPT code 63047. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (76000) provided September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assist (G2067) and take home supply 
methadone (G2078), provided on April 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assist  and take home supply methadone. You say that the service 
should be covered. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medication assist (G2067) and take home 
supply methadone (G2078), provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, 
Monovisc, or Synvisc-One. 
 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 Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Durolane, Monovisc or Synvisc-One. The 
reviewer found that there is no indication that the plan's required drugs would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued admission in a skilled nursing facility 
(SNF). 
 
You asked the Plan to pre-approve a continued SNF admission. You say that you cannot move and require 
additional care within an inpatient setting. The Plan denied your request. The Plan says your request for a 
continued admission in a SNF does not meet the requirements for approval. 
 
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 a continued SNF admission. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 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 a continued SNF admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continued admission in a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided September 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150) provided September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says the criteria for coverage of an ILR have not been met. 
 
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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the appropriateness and medical necessity of implanting an ILR in the clinical 
management of this patient. The patient had a history of post-operative atrial fibrillation in 2018 following 
coronary artery bypass graft surgery, but none since. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients clinical management. 
 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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses you purchased from an out-of-network vendor on 
January 5, 2022. 
 You asked the Plan to pay for the lenses. You say that this claim was denied as a duplicate, but you have only 
submitted this once.  You would like to know why this claim denied. The Plan denied your request. The Plan 
says the denial for 'duplicate claim' was an error.  The Plan is now denying this claim because the provider you 
used is not a network provider. 
 
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 these services only when received from a network vision provider. The provider you 
used is not in the Plan's vision network. Based on this information, we decided that the Plan's rules for 
coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for lenses 
you purchased on January 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had a stroke and need to have rehabilitation. 
You also say that you can only walk with a walker. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that 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: 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 additional rehab to get your strength back. 
The Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and were transferred to skilled nursing. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are not enough studies to show 
the requested procedure is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included 
the facility payment. 
 
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for 
services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to 
this service would have been included under the facility claim. Therefore, we decided that the Plan does not 
have to pay for the services provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that your doctor provided the necessary 
information. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.