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

 
We decided that the Plan does not have to pay for SNF care provided from July 22, 2022, to August 20, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says skilled nursing facility care is no 
longer required. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from July 22, 2022, to August 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours each week for personal care services. 
 
You asked the Plan to pre-approve personal care services. You say that the enrollee needs the additional help 
during the week. The Plan denied your request. The Plan says the additional hours are not medically necessary. 
 
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 is currently enrolled under the Medicare hospice benefit. Therefore, we decided that the Plan does 
not have to pre-approve additional hours each week for personal care services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit and COVID-19 test provided on 
August 19, 2022. 
 
You asked the Plan to pay for the outpatient office visit and COVID-19 test. You say that you called Medicare 
to ask if COVID-19 testing was covered for travel purposes, and you were advised it was covered. You also say 
that you needed this testing since one is continually exposed during this pandemic time. The Plan denied your 
request. The Plan says the COVID-19 screening test for travel was non-coverable as it was not used to 
diagnosis, prevent, or treat a disease or assessment of a medical condition. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the outpatient office visit and COVID-19 test, was requested solely for 
screening purposes so you could travel. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit and COVID-19 test 
provided on August 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on June 23, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say that appealing the denial of the ambulance 
transport. The Plan denied your request. The Plan says the transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance transport. Our reviewer says 
that the service was not medically necessary. Our physician reviewer found you were not bedbound, as 
evidenced by your ability to sit in a wheelchair. You did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van) without endangering your condition. 
 
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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37228, 75716, and 75625 provided on July 
25, 2022. 
 
You asked the Plan to pay for procedure codes 37228, 75716, and 75625. You say that the medical records 
support the billing of codes 37228, 75716, and 75625 provided on July 25, 2022. The Plan denied your request. 
The Plan says the medical records do not support the billing of codes 37228, 75716, and 75625 provided on 
July 25, 2022. 
 
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 37228 is Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. The definition of 
code 75716 is Angiography, extremity, bilateral, radiological supervision and interpretation. The definition of 
code 75625 is Aortography, abdominal, by serialography, radiological supervision and interpretation. 
 We asked our coder 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 procedure codes 37228, 75716, and 75625. Our reviewer 
says that the medical records do not support the billing of codes 37228, 75716, and 75625 provided on July 25, 
2022. Our reviewer found the documentation submitted was reviewed and the medical records do not support 
the billing of code 37228. The operative report does not include enough documentation to confirm 
revascularization with transluminal angioplasty performed per NCCI Policy. In this case, this procedure cannot 
be verified. 
 
The documentation submitted was reviewed and the medical records do not support the billing of code 75716. 
Bilateral extremity radiological supervision and interpretation was performed; however, a revascularization 
(intervention) was performed which includes radiological supervision and interpretation. 
 
The documentation submitted was reviewed and the medical records do not support the billing of code 75625. 
The procedure report does not include documentation of abdominal aortography, and therefore cannot be 
verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37228, 75716, and 75625 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37228, 75716, and 75625 provided on July 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture 
- mandibular (D5120) provided on February 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the services received covered by 
insurance. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on 
February 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services that would be provided in the LTACH are 
being provided in the current acute care setting which is already approved. Therefore, the requested LTACH 
services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee 
at this time. 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and photochromatic tint (V2744) 
provided on August 3, 2022. 
 
You asked the Plan to pay for the frames and photochromatic tint. You say that it seems logical that a new pair 
of glasses would include both the frames and lenses. You also say that the coverage is inadequate for obtaining 
a new pair of glasses. The Plan denied your request. The Plan says the maximum amount covered has been paid 
by the Plan for this service. 
 
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 up to $300 every year for non-Medicare covered prescription eyewear. 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you also received progressive lenses (V2781) 
and anti-reflective coating (V2750) which the Plan applied the full $300 allowance toward on August 3, 2022, 
exhausting your non-Medicare covered prescription eyewear benefit. Based on this information, we decided 
that the Plan's rules for coverage of the frames and photochromatic tint have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020) and photochromatic tint (V2744) provided 
on August 3, 2022.
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 the LTACH services. You say that the LTACH is medically necessary, and 
the enrollee meets the Medicare criteria. The Plan denied your request. The Plan says the LTACH is not 
medically necessary, and then enrollee's needs are being met at the current 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 the enrollee was admitted to the acute care hospital with pneumonia, sepsis, influenza 
requiring antibiotics but complicated by Stevens-Johnson syndrome with wounds requiring treatment. The 
medical record shows the enrollee as having a poor prognosis but has not recently had seizure or unstable vitals 
and is tolerating room air, no longer on dialysis, and requiring additional antibiotics and monitoring. The 
enrollee appears to be more stable on current treatment and should only require short-term additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer to 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips, a non-preferred brand. 
 
You asked the Plan to pre-approve Accu-Chek test strips, a non-preferred brand. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says in your first year with the Plan, 
the Plan provides a 90-day transition period for non-preferred testing supply products. The Plan approved 
transition refills of the non-preferred brand on October 5, 2022, November 3, 2022, and November 28, 2022. 
The Plan says your provider has not provided a medical reason that the preferred brand test strips cannot be 
used. 
 
The Plan must follow Medicare rules. The rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows that your provider has not 
provided a medical reason why you cannot transition to the Plan's preferred diabetic testing supplies. Therefore, 
we decided that the Plan does not have to pre-approve Accu-Chek test strips, a non-preferred brand.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that the power seat elevation system 
would give you the freedom to shop in stores and reach the items on shelves that are currently unreachable. The 
Plan denied your request. The Plan says the power seat elevation system is not covered as they are not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt system for a power wheelchair. 
 You asked the Plan to pre-approve power tilt system. You say that the enrollee meets criteria for a power tilt 
system. The Plan denied your request. The Plan says the enrollee does not meet criteria for a power tilt system. 
 
The Plan follows Medicare rules. Medicare rules state that a power tilt system may be covered if certain 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 power tilt system. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested power tilt system. Our physician 
reviewer found the documentation does not show that the enrollee is at high risk for development of a pressure 
ulcer, utilized intermitted catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. Therefore, a power tilt system exceeds the enrollee's medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power tilt system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power tilt system for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroco. 
 
You asked the Plan to pre-approve Hydroco. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
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 Hydroco.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health aide services. You say that you need this service due to you 
had a stroke not too long ago and have had this service for 5 years. The Plan denied your request. The Plan says 
the services are not medically necessary. 
 
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 home health aide services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found you 
are not homebound. As such, the home health aide services are not medically necessary, reasonable or 
coverable. 
 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the requested epidural steroid 
injections are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet 
criteria for epidural steroid injections. 
 
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 epidural steroid injections. Our 
reviewer says that the enrollee meets criteria for epidural steroid injections. Our physician reviewer found the 
enrollee has chronic low back pain. He has tried Chiropractic and Physical therapy. His medication trials have 
included Mobic, Gabapentin, Tramadol, Flexeril, and Ibuprofen. He had a prior S1 Selective nerve root block 
with "88% pain relief for 9 months." The request is to repeat the blocks. The request meets ALL of the LCD 
criteria and is medically reasonable and 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 epidural steroid injections have been met. Therefore, we decided that the Plan 
has to pre-approve epidural steroid injections.  
 
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 waive the copayment for outpatient surgeries provided on May 11, 
2022, to June 8, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgeries. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $295 
copayment for physician/practitioner services, including doctors office visits. There were 2 outpatient 
surgeries, resulting in a total copayment amount of $590. 
 
You have been asked to pay $295 copayment for each outpatient surgery. This item/service falls within the 
physician/practitioner services, including doctors 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 outpatient surgeries provided on May 11, 2022, to June 8, 2022.