Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for CPAP equipment (A4604, A7030, A7038) 
provided on January 14, 2022, and January 15, 2022. 
 
You asked the Plan to waive the deductible for the CPAP equipment. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Durable Medical Equipment (DME) 
and related supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $250 deductible which applies to Durable Medical Equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the CPAP equipment 
was received on January 14, 2022 to January 15, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for CPAP equipment (A4604, A7030, A7038) provided on January 14, 2022, and January 
15, 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 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 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 enrollee did not have intensive rehabilitation needs. He does have limited 
endurance and there is substantial evidence he cannot tolerate intensive rehabilitation. No indication for 
frequent physiatry oversight. Coverage criteria is not 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 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: Favorable

 
We decided that the Plan has to pay for the computerized corneal topography (92025) provided on March 4, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the computerized corneal topography. You say that your plan does not require 
you to use in-network providers. You also say that it is your choice. The Plan denied your request. The Plan 
says that this is a supplemental service and is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied this service saying it is supplemental and not 
covered. This is an outpatient diagnostic test which is covered by Medicare. Your contract offers both in-
network and out-of-network benefits. The Plan did not provide valid evidence showing why their denial reason 
was correct. Therefore, we decided that the Plan has to pay for the computerized corneal topography (92025) 
provided on March 4, 2022 by an out-of-network (OON) provider.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from July 18, 2022, 
forward. 
 
You asked the Plan to pre-approve the inpatient psychiatric admission. You say that it is the opinion of the 
admitting physician and professional staff that the enrollee meets admission and continued stay criteria for 
inpatient care. The Plan denied your request. The Plan says this request is not medically necessary because the 
records received show that the services being delivered can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our 
physician reviewer found it was not expected this enrollee would improve in a reasonable period of time for the 
dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of 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 the inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission from July 18, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the progressive lens (V2781) provided on September 
15, 2021.  
You asked the Plan to pay more for the progressive lens. You say that you would like to appeal this service. 
The Plan denied your request. The Plan says the cost-share applied is correct based on the Plan 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 covers eyeglasses after cataract surgery including standard frames and lenses as defined by 
Medicare; any upgrades are not covered. 
 
We looked at the file and the Plan's rules. The record shows that you received progressive lens, which the 
Evidence of Coverage clearly states is not covered. However, the Plan offered a 20% discount, and you are 
responsible for the remaining amount. Based on this information, we decided that the Plan's rules for coverage 
of the progressive lens have not been met. Therefore, we decided that the Plan does not have to pay more for 
the progressive lens (V2781) provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 28, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 28, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of care plans and the home visit provided on 
November 30, 2021, to March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for revision of care plans and the home visit. You say that the services are Medicare-
covered services, and the services were medically necessary. The Plan denied your request. The Plan says no 
prior authorizations were 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
revision of care plans and the home visit. We found no exception that would require the Plan to pay for the 
revision of care plans and the home visit. The records provided for review do not show that the services at issue 
were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the revision of care plans 
and the home visit provided on November 30, 2021, to March 4, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for discharge to a lower level of care such as in a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service November 
24, 2021. 
 You asked the Plan to pay for procedure code 93010. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 31500. 
 
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 93010 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service November 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on February 2, 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 the service was rendered by an out-of-network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on February 2, 2022.
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 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 cardiac event monitors are covered when specific 
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 an ILR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found while the enrollee has a history of atrial 
fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Supartz (J7321). 
 
You asked the Plan to pre-approve Supartz. The Plan denied your request. The Plan says that in order for 
patients with arthritis of the knee to have more knee injections, it is necessary to have significantly less pain 
and better movement of the knee after previous injections of the knee. The Plan also says that recent notes 
provided from show the enrollee only had a couple of days of relief from their last injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Supartz. Our reviewer says that Supartz 
is reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of osteoarthritis of the knee. The documentation indicates that the enrollee received viscosupplementation on 
October 4, 2022. Our reviewer found that upon follow-up in June 2022 it was noted that the enrollee had 
experienced improvement following the injection. The Food and Drug Administration has stated that the 
requested drug is indicated for the enrollee's condition. The elements of the coverage criteria are satisfied. Our 
physician reviewer also found that the requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have been met. Therefore, we decided that the Plan has to pre-approve 
Supartz (J7321).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on June 7, 
2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the medical records do not 
support the services as billed. 
 
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 99152 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; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the medical records do not 
document that an independent trained observer was involved with the services in question. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a massage chair provided March 13, 2022. 
 
You asked the Plan to pay for the massage chair. You say that the chair was medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a massage chair provided March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says the facet joint injections do not meet the Medicare coverage 
criteria. 
 
The Plan follows Medicare 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 pre-approve facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found The efficacy of C1-C2 facet injections is controversial and is excluded by both the Medicare NCD and LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the 
lower extremity (73723). 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says imaging requires six 
weeks of provider directed treatment to be completed. The Plan also says that the enrollee has not completed 
six weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that an MRI 
is not reasonable and necessary. Our physician reviewer found the request is for an MRI of the left knee 
without and with contrast. The rationale for needing intravenous (IV) contrast enhancement is not explained in 
the records. Our reviewer found there is no mentioned suspicion of tumor or infection. The patient presented 
with knee swelling and instability.  Our physician reviewer also found that the rationale for the request to have 
IV contrast enhancement is not clear. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of any joint of the lower extremity (73723).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 15, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would like this claim to be processed and paid. The Plan denied your request. The Plan says the enrollee 
had elected Hospice Services on this same date of service, December 15, 2021. The Plan also says that 
traditional Medicare pays for hospice services, and this request remains denied. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 15, 2021.