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

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2799, V2781) provided on January 
26, 2022. 
 You asked the Plan to pay for eyeglasses. You say that the provider told you that you could be reimbursed for 
these services, and they took your insurance. The Plan denied your request. The Plan says the provider in this 
case is not part of the Plan's network. Items/services purchased outside of this network are not covered. 
 
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 in the Plans specified vision 
vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified vision 
vendor network. Please note that out-of-network providers are not agents of the Plan. Based on this 
information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses (V2025, V2799, V2781) provided on January 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve ablation provided on October 19, 2021. 
 
You asked the Plan to pay for the genicular nerve ablation. The Plan denied your request. The Plan says this 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 genicular nerve ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is considered an experimental/investigational procedure at this time. 
Therefore, the procedure was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve ablation provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 
28, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that it does not make sense that 
CPT code 99152 was paid, and CPT code 99153 was not. You say that the documents support the performance 
of these services, and the doctor is entitled to reimbursement. The Plan denied your request. The Plan says CPT 
code 72275 has been overturned and CPT code 99153 remains denied as the provider did not bill as required by 
Medicare coding regulations. 
 
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 code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
  
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 these services. Our reviewer says that 
the services are not medically necessary Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine vision services you received on December 13, 2021, 
with an out-of-network (OON) provider. 
 You asked the Plan to pay for the OON vision services. You say that you were not aware that you had to get 
prior authorization because you have been going to this provider for years when you had other insurance. The 
Plan denied your request. The Plan says OON vision services are not covered. 
 
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 [Insert why/when the plan covers routine vision]. 
 
We looked at the file and the Plan's rules. Under your Plan's contract, you only have coverage for routine vision 
care if you use the Plan's designated vision provider.  You did not use the Plan's designated vision provider. 
Based on this information, we decided that the Plan's rules for coverage of the OON vision services have not 
been met. Therefore, we decided that the Plan does not have to pay for routine vision services you received on 
December 13, 2021, with 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that records do not indicate that there are significant or complex 
medical/nursing issues that could not be addressed at a lesser level of 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall. The enrollees 
medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has 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 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a gastric pacemaker. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has objectively demonstrated gastroparesis, with associated symptoms that have shown 
inadequate response to conventional medical management. Gastric electrical neuro-stimulation is a viable 
option that is used commonly in clinical gastrointestinal practice for refractory patients, such as the enrollee. 
The technique may offer improvement in the enrollee's symptoms as described. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve implantation of a gastric pacemaker.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided November 23, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on November 23, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is doing well with his current equipment. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requirements for coverage of the requested ventilator have not been met. Our physician reviewer found 
there is no recent clinical note in the medical records indicating a need for ventilatory support during sleep. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging (code 92134) provided on January 3, 2022, and February 28, 2022. 
 
You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for scanning computerized ophthalmic diagnostic imaging. The 
scanning computerized ophthalmic diagnostic imaging (code 92134) 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 
scanning computerized ophthalmic diagnostic imaging provided on January 3, 2022, and February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
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 medical studies haven't proven this service/item is helpful for the 
treatment of your health problem. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. 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 the Vertiflex Superion Interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance you received on December 29, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you are covered for this service two 
times a year and you only had two visits in 2021. The Plan denied your request. The Plan says you were not 
eligible for this service on December 29, 2021. 
 
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. Your dental benefit includes 
coverage of periodontal maintenance once every 6 months.  Records show that you received a covered 
periodontal maintenance service on July 20, 2021, so you would not have been eligible for another one until 
after January 20, 2022.  The periodontal maintenance you had on December 29, 2021, was before this date, so 
you were not eligible for this service. 
 
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 pay for 
periodontal maintenance you received on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric restrictive laparoscopy (43770). 
 
You asked the Plan to pre-approve a gastric restrictive laparoscopy. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a gastric restrictive laparoscopy have not been met. Specifically, the available medical records do not document a BMI of greater than or equal to 35. Therefore, we 
decided that the Plan does not have to pre-approve a gastric restrictive laparoscopy (43770).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this procedure is unproven. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested 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 it is safe 
and effective. 
 
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 insertion of a Vertiflex device have not been met. 
 
 
  
 
 Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 
22870).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter coronavirus test purchased on January 
14, 2022. 
 
You asked the Plan to pay for the over-the-counter coronavirus test. You say that this is a medical item. You 
also say that it should be covered by your health plan. The Plan denied your request. The Plan says the item 
was not covered on the date it was purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that plans or issuers may, but are not required by 
federal law to, provide such coverage for at-home over-the-counter COVID-19 tests purchased before January 
15. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the over-the-counter coronavirus test have not been met. Specifically, the item was purchased prior 
to January 15, 2022. Therefore, we decided that the Plan does not have to pay for the over-the-counter 
coronavirus test purchased on January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine pads. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Lidocaine pads.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for the surgery services provided on November 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse payment for the surgery services. You say that your primary care provider 
referred you to the OON provider and the procedure done was medically necessary. The Plan denied your 
request. The Plan says an approved authorization was for one visit to the OON provider in December 2020 for 
a second opinion. There was an approved authorization for an in-network provider who was fully capable of 
providing the same services. Also, the procedure rendered was not urgent or emergent. 
 
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 reimburse payment 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 reimburse payment for these 
items/services. Therefore, we decided that the Plan does not have to reimburse payment for the surgery services 
provided on November 18, 2021, by an out-of-network (OON) provider.