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

 
We decided that the Plan does not have to pay for an annual wellness visit provided on December 5, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were leaving the country for 
approximately two months and believed a checkup was needed and you could not wait until the period of your 
annual checkup due date. The Plan denied your request. The Plan says the Plan did not find any unique 
circumstances that would allow payment for a second annual wellness visit for the 2022 calendar year. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on 
December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the frames, and the routine eye 
examination provided on November 4, 2022, 
 
You asked the Plan to pay for the progressive lens, the frames, and the routine eye examination. You say that 
you were told that you could go to this provider to get your glasses. You say you cannot afford this bill. The 
Plan denied your request. The Plan says the provider was out-of-network. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens, the frames, and the routine 
eye examination have not been met. Therefore, we decided that the Plan does not have to pay for the 
progressive lens, the frames, and the routine eye examination provided on November 4, 2022,
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Roux-en-Y gastric bypass. 
 
You asked the Plan to pre-approve Roux-en-Y gastric bypass. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on and after 
February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic 
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch 
(BPD/GRDS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries 
who have a body-mass index = 35, have at least one co-morbidity related to obesity, and have been previously 
unsuccessful with medical treatment for obesity. 
 
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 Roux-en-Y gastric bypass. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the standard treatment 
for medically refractory gastroesophageal reflux disease (GERD) after sleeve gastrectomy is conversion to 
gastric bypass as these patients are not able to undergo a standard anti-reflux procedure, given the absence of 
the fundus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Roux-en-Y gastric bypass have been met. Therefore, we decided that the Plan 
has to pre-approve Roux-en-Y gastric bypass.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-autogenous connective tissue graft (D4275). 
 
You asked the Plan to pre-approve non-autogenous connective tissue graft. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve non-
autogenous connective tissue graft (D4275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on September 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you want to appeal this. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 telehealth visit provided on September 13, 
2022, by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit, and diagnostic radiology 
procedures provided on November 8, 2022. 
 
You asked the Plan to pay for the emergency department visit, and diagnostic radiology procedures. You say 
that the services were medically necessary. The Plan denied your request. The Plan says codes 72100 and 
73562 have a status indicator of Q1 according to Addendum B - OPPS Payment by HCPCS Code for CY 2022. CPT 99284 was billed on the same date of service with a revenue code of 450 which according to the 
I/OCE Quarterly Release Files has a status indicator of V (clinic or emergency department visit). Therefore, 
CPT codes 72100 and 73562 are not separately payable according to Medicare Claims Processing Manual 
Chapter 4 - Part B Hospital, Section 10.4, C, 2. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this emergency department is not affiliated with a 
hospital. Based on this information, we decided that Medicare rules for coverage of the emergency department 
visit, and diagnostic radiology procedures have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit, and diagnostic radiology procedures provided on  
November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a reverse total shoulder arthroplasty. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a reverse total shoulder arthroplasty to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99222) provided on September 2, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Evidence of Benefits (EOB) was not received from the enrollee's 
primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
multiple attempts to contact the provider for a coordination of benefits (COB).. As the secondary insurer, the 
Plan cannot be held responsible for the hospital care until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided 
on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing service (V5299), hearing aid (V5221), hearing 
aid fitting (V5011), dispensing fee (V5160), and the ear mold (V5264) provided from April 22, 2022, through 
December 21, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services are not payable as 
they were rendered by an out-of-network provider. Additionally, ear molds are not a covered benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
  
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the Plans contract provides coverage for 
hearing aids/services purchased only through the Plans select hearing aid provider. However, the 
items/services in this case were rendered by an out-of-network provider. Additionally, ear molds are not a 
covered benefit.  Therefore, we decided that the Plan does not have to pay for the hearing service (V5299), hearing aid (V5221), 
hearing aid fitting (V5011), dispensing fee (V5160), and the ear mold (V5264) provided from April 22, 2022, 
through December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on August 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on June 17, 2021. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 95937-26, 95907-26, 95955-26-XU, and 95885-26-59 is 
neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, by any 1 method; nerve 
conduction studies for 1-2 studies; electroencephalogram (EEG) during nonintracranial surgery (carotid 
surgery), limited needle electromyography, per each extremity with related paraspinal areas when performed, 
done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for 
primary procedure). 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the services provided were reported 
incorrectly and cannot be verified by the documentation provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on June 17, 2021.
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 will be able to make enough progress with 
inpatient rehabilitation to come home with minimal care. The Plan denied your request. The Plan says you do 
not meet the Medicare criteria for admission to an Inpatient Rehabilitation 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pre-approve surgical placement of implant body: endosteal implant 
(D6010) and bone replacement graft for ridge preservation - per site (D7953) Tooth #8. 
 
You asked the Plan to pre-approve dental services. You say that your tooth is extremely sensitive, it needs to be 
pulled and an implant put in. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Surgical placement of implant 
body: endosteal implant (D6010) and bone replacement graft for ridge preservation - per site (D7953) are not 
covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010 and D7953 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant (D6010) and bone replacement graft for ridge 
preservation - per site (D7953) Tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day Sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 day Sensor. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
 
 
 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. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre 14 day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14 day Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour Next Blood Glucose test strips. 
 
You asked the Plan to pre-approve a Contour Next Blood Glucose test strips. You say that this glucose monitor 
is medically necessary. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Contour Next Blood Glucose test strips. Therefore, we decided that the Plan does not have to pre-approve 
a Contour Next Blood Glucose test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Maze procedure. 
 
You asked the Plan to pre-approve a Maze procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet specific conditions. 
 
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 Maze procedure. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while there have been published 
reports of the success of epicardial MAZE procedures for persistent atrial fibrillation, there have been no 
controlled clinical trials establishing its clinical efficacy. As such, bilateral thoracoscopic, epicardial MAZE 
procedure would not be considered medically appropriate and necessary in this enrollees 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 a Maze procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Maze procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement implant (D7994), abutment 
supported crown (D6059), custom fabricated abutment (D6057), interim abutment teeth (D6051), dental 
implant (D6010), modification of removable prosthesis (D5875), treatment simulation (D0393) and cone beam 
(D0367). 
 
You asked the Plan to pre-approve the dental services. You say that these should be covered. The Plan denied 
your request. The Plan says your benefit for abutment supported crown (D6059), custom fabricated abutment 
(D6057), dental implant (D6010) and interim abutment teeth (D6051) has already been exhausted.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement, implant (D7994), abutment supported crown (D6059), custom 
fabricated abutment (D6057), interim abutment teeth (D6051), dental implant (D6010), modification of 
removable prosthesis (D5875), treatment simulation (D0393) and cone beam (D0367).