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

 
We decided that the Plan does not have to pre-approve guided tissue regenerations (D4266), bone grafts at the 
time of implant placement (D6104), second stage implant surgeries (D6011) and removal of torus mandibularis 
(D7473). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefit. 
 
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 guided tissue regenerations (D4266), bone grafts at the time of implant placement (D6104), second stage 
implant surgeries (D6011) and removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eyeglass frame and lens option package and fundus 
photography (92250) provided on October 11, 2021. 
 
You asked the Plan to pay for vision services. You say that you do not agree with the member responsibility of 
this claim. You say that you thought these charges were covered under your policy. The Plan denied your 
request. The Plan says you exceeded the $200 vision allowance benefit. The Plan also says an eye exam with 
photos is not a covered benefit. 
 
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 contract says you have a $200 allowance once per year to use towards eyewear. 
 
We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed 
benefit. The records also show you purchased a frame and lens option package for $577. The Plan applied your 
$200 allowance which left you with a balance of $377 ($577 - $200 = $377). The Plan also applied a 20% off 
discount, (20% of $377 = $75.40). The records also show that you had fundus photography which is not a 
covered benefit with your Plan. The allowed amount is $39, and you are responsible for this cost. Your total 
cost share is $340.60 ($377 - $75.40 = $301.60 + $39 = $340.60). Based on this information, we decided that 
the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not 
have to pay for an eyeglass frame and lens option package and fundus photography (92250) provided on 
October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levetiracetam ER for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Levetiracetam ER for the 
enrollee.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on September 24, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that the in-network benefits should be honored, and the claim should be processed for payment. 
The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on September 24, 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 the enrollee is ready for rehabilitation. The Plan 
denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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. The enrollee 
does not require treatment by multiple therapies including an intensive rehabilitation therapy program. There is 
not a reasonable expectation that the enrollee 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic exercises (97110) to be rendered by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the therapeutic exercises. The Plan denied your request. The Plan says the 
requested treating provider is not part of the enrollee's insurance plan, and the enrollee must use an in-network 
provider. The Plan also says that there are 700 participating providers and 20 hospitals within a 50-mile radius 
of the enrollee's home. 
 
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 
therapeutic exercises (97110) to be rendered 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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical 
therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting 
such as in a skilled nursing facility or in-home with services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you already have the equipment from a 
previous insurance and would like to keep it. The Plan denied your request. The Plan says the provider is an 
out-of-network provider, and an in-network provider was given, additionally the Plan approved 4 months to 
give the enrollee time to re-order the equipment. 
 
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 power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids (V5298) provided on April 25, 2021. 
 
You asked the Plan to reimburse you for hearing aids. You say that you contacted the Plan, and you were given 
instructions on how to proceed with your hearing aids. You would like to be reimbursed. The Plan denied your 
request. The Plan says there is no coverage for hearing aids when received from a provider other than the Plan 
specified hearing aid vendor. 
 
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. The Plan pays for 
hearing aids only when provided by the Plans hearing aid provider.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5298) 
provided on April 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance 
transportation (A0428) provided on October 2, 2021. 
 
You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that 
the enrollee did meet the medical necessity requirements since they are bed confined, unable to ambulate, lack 
of coordination, and high fall risk. You also say that you would like this denial to be overturned. The Plan 
denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a 
scheduled non-urgent visit is not a Medicare covered benefit. The Plan also says that there was no documented 
acute, urgent, or emergent condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 ground mileage and non-emergency 
ambulance transportation. Our reviewer says that the documentation does not support that the ambulance 
transport on October 2, 2021 was medically reasonable and necessary for the enrollee. Our physician reviewer 
found the documentation does not support that other means of transport (such as stretcher van) were 
contraindicated for this enrollee. Our reviewer also found that the documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance could provide for safe transport on October 2, 2021. 
 
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 ground mileage and non-emergency ambulance transportation have not been 
met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on October 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on December 3, 
2020. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on December 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) tubing (S1015) and infection control 
supplies (S8301) provided on September 16, 2021. 
 
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like 
reconsideration because you supplied this equipment at your own cost. The Plan denied your request. The Plan 
says CPT codes S1015 and S8301 are not valid for Medicare purposes. 
 
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 codes S1015 and S8301 are not supported in the medical record. Specifically, CPT codes 
S1015 and S8301 both have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid 
for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV 
tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for the intravenous (IV) tubing (S1015) and infection control supplies (S8301) provided on September 16, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2520) provided on October 4, 2021. 
 
You asked the Plan to pay for contact lenses. You say that the denial explanation does not make sense, as you 
are a private optometry practice that provides service to the patients. The Plan denied your request. The Plan 
says the service item was billed with an incorrect place of service. 
 
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 V2520 is not supported in the medical record. Specifically, this claim was billed with 
the office place of service code. The place of service code for durable medical equipment should reflect the 
place in which the item is being used. The office place of service code is not appropriate in this case. Based on 
this information, we decided that Medicare rules for coverage of contact lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for contact lenses (V2520) provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no imaging that supports this diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections can be covered if 
Medicare criteria are met. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. You have 
radiculopathy but there is no documentation of imaging that supports this diagnosis. There are imaging reports, 
however, these are all fluoroscopic imaging related to sacroiliac procedures. Within the initial request for this 
ESI, it was documented that no recent imaging study has been performed. Our physician reviewer found that 
your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic ultrasound rendered on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76856 (pelvic ultrasound) and 93975 (vascular study). 
Code 76856 is a column II code with a modifier indicator of 1 when billed with column I code 93975. Code 
76856 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the pelvic ultrasound rendered on September 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the therapeutic exercises (97110), manual 
therapy techniques (97140), and the physical therapy evaluation (97161) provided from October 8, 2021, 
through November 23, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $40 
copayment for Medicare-covered physical therapy services rendered by an in-network provider.   
  
You have been asked to pay $429.22 ($40 copayment x 10 + $29.22) for the physical therapy services rendered 
by an in-network provider. This amount is less than the total applicable copayments for these services. 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 copayments for the therapeutic exercises (97110), manual therapy 
techniques (97140), and the physical therapy evaluation (97161) provided from October 8, 2021, through 
November 23, 2021.