Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 1, 2021, through January 31, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you believe that there should have been an 
evaluation before your coverage switched to your new plan, because this would have shown that the enrollee 
still required daily skilled services to return to being able to walk. You feel that this denial is not correct since 
skilled care should have been provided. The Plan denied your request. The Plan says the services provided on 
the dates at issue were not authorized and were custodial in nature. These were correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the member is a 77-yr-old male with a 
medical history including cardiac disease, chronic neck pain, retention of urine and Parkinson's disease who 
was admitted to a skilled nursing facility on 12/3/2020 for skilled rehab services. The documentation indicates 
that by 1/1/21 the resident did not have any skilled nursing needs. He had been discharged from skilled rehab 
services due to a plateau in functional improvement and due to his refusal to cooperate with rehab services. He 
was able to propel himself in a wheelchair and continued to require extensive assistance with transfers. 
 
As of 1/1/21 the member did not require any skilled nursing or rehab services on a daily basis.  He was not 
expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or ADLs.  The member did not require skilled therapy to 
establish a safe and effective maintenance program.  As a practical matter, the member did not require any 
skilled services on an inpatient basis, at a SNF level of care as of 1/1/21. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, through January 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical vision office visit provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for the medical vision office visit. You say that the claim should 
have been billed to the vision vendor and therefore should have been processed under routine vision services. 
The Plan denied your request. The Plan says the primary diagnosis code billed on claim was H18.621 for 
Keratoconus, unstable, right eye which is a medical related diagnosis code and does not fall under the routine 
vision benefits services. This claim was processed correctly according to the members 2021 Evidence of 
Coverage. 
 
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 Vision Care, Medicare Covered Vision Services, Specialist's Office.  You have been asked to pay a $40 copayment for the medical vision office visit. The medical vision office visit 
falls within the Vision Care, Medicare Covered Vision Services, Specialist's Office 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 a medical vision office visit provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Vertiflex superion interspinous device is not indicated in this enrollee given multi-
level disease, greater than two (2) levels, as seen on the magnetic resonance imaging (MRI) of the spine with 
severe canal stenosis L2-L3, L4-L 5 and L5-S1. The Plan states placement of Vertiflex at L4-L5 will not 
address the stenosis at the other levels. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex superion interspinous device at L4-5, in this case, is 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance to be provided 
by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says 
there are in-network providers that are able to provide these services. Therefore, coverage criteria 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 pneumatic compressor and segmental pneumatic appliance 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 waive the copayment for a primary care physician (PCP) office visit 
provided on September 24, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that you were charged for an 
annual visit. You say that you do not know what can or cannot be discussed. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 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 no 
copayment, coinsurance, or deductible for the annual wellness visit. 
 
Your contract with the Plan also clearly says that you must pay a $20 copayment for provider and professional 
services received at a PCP's office.  
 
The file shows that you had discussed Vitamin D deficiency, high blood pressure, high cholesterol, and 
shoulder and knee pain. These issues go beyond the scope of a wellness visit. Therefore, you have been asked 
to pay a $20 copayment for the PCP office visit. The PCP office visit falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits 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 a primary care physician (PCP) office visit provided on September 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intravascular ultrasound followed by angioplasty 
(vein dilation) and stenting. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because there are other options available to the 
enrollee that are universally acceptable among the medical professional community and provide benefit. The 
Plan states the request exceeds the enrollee's current medical need. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support the medical necessity of the additional invasive venous 
procedures requested. There is no documentation of whole leg edema and no documentation of physiologic 
proximal obstruction on noninvasive studies. The maximal diameter reduction noted on IVUS was 52.5 % in 
the left common iliac vein. It is not clear what the enrollees response to the seven (7) procedures performed so 
far were; furthermore, recent evaluation describes that the enrollees symptoms are in the right leg - however, it 
is left iliac that is being considered for venous stenting. Our physician reviewer agrees with the plan position 
that the request exceeds the enrollees current medical need.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intravascular ultrasound followed by angioplasty (vein dilation) and stenting.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (87635) provided on August 16, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because you 
were told that COVID-19 testing would be paid in full. The Plan denied your request. The Plan says the claim 
processed correctly according to the allowable amount. 
 
The Plan must follow Medicare rules. Medicare rules say that for services of a non-contracting, original 
Medicare, participating provider; there is no balance billing paid by either the plan or the enrollee. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 testing have not been met. Specifically, the record indicates that the Plan 
reimbursed you the Medicare allowed amount for the COVID-19 testing. The record also indicates that this 
testing was rendered by an out-of-network provider. The Plan is not responsible for payment of the balance. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 testing (87635) provided on 
August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for a medical eye exam (92004) and an eye refraction (92015) 
provided on October 13, 2021, with an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical eye exam and an eye refraction. You say that you did not know that 
the provider was not a Plan provider. You also say you would like a one-time exception for this visit. The Plan 
denied your request. The Plan says an eye refraction is not covered OON, and you are responsible for the entire 
cost. The Plan also says that you pay a 20% coinsurance for each visit with an OON provider. 
 
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 that you pay a 20% coinsurance for each Medicare-covered visit with an OON 
provider. The Plan contract also says that an eye refraction is not covered OON. 
 
We looked at the file and the Plan's rules. The EOC confirms that if you receive services from an OON 
provider, you pay a 20% coinsurance for the visit. The EOC also confirms that an eye refraction is not covered 
by an OON provider. The records show the provider was not in network; therefore, you owe a 20% coinsurance 
in the amount of $30.50 for the medical eye exam and you are responsible for the entire cost of the eye 
refraction. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam and 
an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye 
exam (92004) and an eye refraction (92015) provided on October 13, 2021, with an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion destruction (17000) provided on July 19, 2021. 
  You asked the Plan to pay for the lesion destruction (17000). You say that these codes were medically 
necessary and codes 17000 and 17003 should be processed separately. The Plan denied your request. The Plan 
says an appropriate modifier was not billed with this code edit. 
 
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 17000 
is a column II code to column I code 11102. 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 the lesion destruction (17000) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ROMTech PortableConnect. 
 
You asked the Plan to pre-approve the ROMTech PortableConnect. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says 
this equipment is considered a comfort/convenience item. 
 
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 ROMTech PortableConnect. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device exceeds your medical needs. The documentation does not reveal 
extenuating factors that require this blue tooth enabled device for your home rehabilitation needs over standard 
therapy practices and evaluations. 
 
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 ROMTech PortableConnect have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the ROMTech PortableConnect.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not been shown 
to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer 
devices are as safe and effective as the gold standard of decompression. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex superion interspinous device at L3/4 is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the clinical value and effectiveness of 
Keytruda in the setting of treatment beyond 24 months duration has not been demonstrated in the peer-
reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on October 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and there is not a 
referring provider and there is no evidence that this is 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on October 15, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99214) provided on August 9, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physician office visit (99214) provided on 
August 9, 2021, by an out-of-network provider.