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

 
We decided that the Plan does not have to pay for the eye exam (92014), frames (V2020), bifocal lens (V2200), 
tint (V2745), and progressive lens (V2781) provided on March 8, 2022. 
 
You asked the Plan to pay for the eye exam and glasses. You say that you were told that you were eligible for 
coverage for glasses in March, and were not told a specific date you had to go. The Plan denied your request. 
The Plan says your benefit maximum has been met, and these 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 every 2 years. 
 
 
 
 
 We looked at the file and the Plan's rules. The contract clearly states that this benefit is administered on a 
rolling calendar year since your last date of service. The record shows that you last received glasses on March 
9, 2020. Based on this information, we decided that the Plan's rules for coverage of the eye exam and glasses 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014), frames 
(V2020), bifocal lens (V2200), tint (V2745), and progressive lens (V2781) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this fee is in addition to the primary 
anesthesia procedure and is separately payable based on guidelines. You say that the description of services 
documents the qualifying circumstances that enable this code to be paid. The Plan denied your request. The 
Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5130 billed for date of service March 20, 
2022, through March 26, 2022. 
 
You asked the Plan to pay for procedure code S5130. The Plan denied your request. The Plan says the billed 
code is invalid 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 procedure code. 
 
 
  We find that procedure code S5130 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5130 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5130 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5130 billed for date of service March 20, 2022, through March 26, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on February 13, 2022.  You asked the Plan to pay for lab services. You say that these services were necessary in determining the 
appropriate medical treatment for the enrollee. The Plan denied your request. The Plan says original Medicare 
is responsible for payment. 
 
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 laboratory (lab) services provided on February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing does not meet the 
Medicare LCD 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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary. Our physician reviewer found that 
based on review the records provided, this enrollee has had difficulty with cognitive ability. The documentation 
shows this enrollee to have memory loss. There is no documented neurologic evaluation or medical evaluation. 
Utilizing the criteria from LCD L33632 that this testing is intended to diagnose and characterize the 
neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including 
detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential 
diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central 
nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system 
disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the criteria as the 
enrollee has not been evaluated medically or neurologically and is therefore neuropsychological testing does 
not appear medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair you purchased from a furniture store on January 
24, 2022. 
 
You asked the Plan to pay for the lift chair. You say that you were not aware that you needed to get 
authorization to get this chair.  You said that you have had medical problems with your legs for years that got 
worse in 2021. The Plan denied your request. The Plan says the supplier from whom you purchased this chair is 
not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
lift chair you purchased from a furniture store on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis of 324 genes (0037U) 
provided on January 19, 2022. 
 
You asked the Plan to pay for targeted genomic sequence analysis. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the requested panel includes the FANCC gene; 
therefore, this service is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests 
that include the FANCC gene.  
 
We looked at the file and Medicare rules. The panel at issue includes testing for the FANCC gene. Based on 
this information, we decided that Medicare rules for coverage of targeted genomic sequence analysis have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis of 
324 genes (0037U) provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physical therapy provided to the enrollee 
from April 1, 2022, to April 13, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physical therapy provided to the 
enrollee from April 1, 2022, to April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test 
 
You asked the Plan to pre-approve the Cologuard test. You say that you are having symptoms of weight loss 
and your physician would like you to get screened. The Plan denied your request. The Plan says the enrollee 
does not meet the coverage criteria as she is symptomatic and above the age limit outlined in the Medicare 
National Coverage Determination. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard test are covered once every 3 years 
when the enrollee is between the age of 50 to 85.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cologuard test have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Cologuard test
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of the veins. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the records provide medical 
necessity for this service. The Plan denied your request. The Plan says the patient has not had a CEAP or 
Venous Clinical Severity score assessment, documentation of the impact of venous insufficiency on activities 
of daily living, or that the patient has tried conservative measures. 
 
The Plan follows Medicare rules. Medicare rules say that Thermal ablation (radiofrequency or laser) will be 
considered medically reasonable and necessary for ablation of incompetent saphenous veins for the treatment 
of patients with symptomatic CEAP clinical classification C2 to C6 disease. 
 
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 endovenous ablation therapy. Our 
reviewer says that endovenous ablation therapy is not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee has signs and/or symptoms that interfere with activities of 
daily living and/or quality of life. The case file does not contain documentation of a 2 to 4-week period of conservative therapy, including compression 20-30 mmHg or greater, ambulation, elevation, and avoidance of 
prolonged sitting or standing 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of the veins.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service, 
February 3, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was reported correctly and is supported in 
the medical record. The Plan denied your request. The Plan says this service is not supported 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Without this information, a time-based code such as 99291 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of critical care have not been 
met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for date 
of service, February 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services provided on August 30, 2021. 
 
You asked the Plan to pay for hospital discharge services. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
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 hospital discharge services provided on August 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (7 hours a day, 7 days a week). 
 
You asked the Plan to pre-approve the services. You say that nothing has been changed in the enrollee's 
medical condition to have warranted this reduction in service. The Plan denied your request. The Plan says 3 
hours a day, 7 days a week is appropriate and has been approved. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide hours are not medically reasonable or necessary. Our physician reviewer found that in this case, 
you are medically stable without any recent hospitalizations or medical complications. The approved weekly 
hours allow for appropriate support and care. The documentation does not support that the additional hours are 
needed to provide adequate support. 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 a home health aide (7 hours a day, 7 days a week).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the $40.33 copayment for a pacemaker system programming on January 
27, 2022. 
 
You asked the Plan to waive the $40.33 copayment for a pacemaker system programming. You say that you 
would like reconsideration because you feel the copayment was applied in error. The Plan denied your request. 
The Plan says that the cost share has been applied correctly. 
 
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 has not forwarded the correct EOC. Without the contract, 
we are unable to verify your benefits and determine if the cost sharing has been applied correctly. Of note, we 
requested the correct EOC from the Plan and did not receive it. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to waive the $40.33 copayment for a pacemaker system 
programming on January 27, 2022.  
 
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 domiciliary services provided on February 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 domiciliary services provided on February 8, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is weaker than baseline, has limited 
ability to self-transfer and needs wound vac care. The Plan denied your request. The Plan says the enrollee does 
meet the health condition for a SNF stay. 
 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 pre-approve SNF care. Our reviewer says that SNF 
care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018-26 billed for date of service February 
28, 2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the medical records support payment for 
these services. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 16, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 74018 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74018-26 billed for date of service 
February 28, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says criteria for admission to the IRF setting have 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation 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.