Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 2, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code was partially paid. The Plan denied your request. The Plan 
says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that the date of service, 
February 18, 2021, was paid due to an administrative error. 
 
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 therapeutic exercises (97110) provided on June 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 14, 
2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for Outpatient surgery.  
 
   
You have been asked to pay a $290 copayment for a colonoscopy. Colonoscopies fall within the Outpatient 
surgery 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 colonoscopy provided on 
December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services provided from 
November 30, 2021, to December 2, 2021. 
 
You asked the Plan to waive the copayment for the advanced imaging services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient hospital services.  
 
 You have been asked to pay a $170.69 copayment for advanced imaging services, which is less than the 
standard $250. Advanced imaging services falls within the Outpatient hospital services 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 advanced imaging services provided from November 30, 
2021, to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computerized corneal topography (92025) provided on 
September 10, 2021. 
 
You asked the Plan to pay for corneal topography. You say that this service was medically necessary and 
appropriate. The Plan denied your request. The Plan says the requested service is not medically necessary and 
is not appropriate in the setting of pre-operative assessment for cataract surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for corneal topography. 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 that the enrollee has an eye condition for 
which computerized corneal topography would be medically reasonable and necessary prior to cataract surgery, 
such as irregular astigmatism or a corneal ulcer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of corneal topography have not been met. Therefore, we decided that the Plan does 
not have to pay for computerized corneal topography (92025) provided on September 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need spinal rehab care. The Plan denied 
your request. The Plan says you do not require daily skilled nursing or therapy services on a inpatient basis. 
 
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 services. Our physician reviewer 
found that you were admitted to the acute care hospital for a planned decompression and fusion of T10-S1. The 
most recent therapy documentation indicates you are able to ambulate up to 85 feet independently. You only 
require supervision for mobility. You are medically stable without any acute exacerbations of chronic medical 
problems. Your physical function is at or near baseline. Therefore, SNF services are not medically reasonable 
or necessary at this time.   
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve storage of embryos, per year (89342). 
 
You asked the Plan to pre-approve storage of embryos, per year. You say that this procedure should be a 
covered benefit with your Plan. You also say you do not agree with the denial. The Plan denied your request. 
The Plan says the requested service is not a covered benefit with your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare is a defined benefit program. Services 
that do not fit into an established benefit category are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of storage of embryos, per year have not been met. Specifically, the requested service is not a covered 
benefit with the Plan. Therefore, we decided that the Plan does not have to pre-approve storage of embryos, per 
year (89342).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that this would allow you to go outside and get 
around your home. The Plan denied your request. The Plan says that records do not support the need for a 
power scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD can be covered if Medicare criteria have been 
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 a power scooter. Our reviewer says that 
a power scooter is not medically reasonable and necessary. The documentation does not state that you have a 
mobility deficit that impairs MRADLs in the home and this mobility limitation. The documentation states you 
cannot propel a manual wheelchair. The documentation is not clear that you cannot use a cane or walker. While 
you may have the cognition to safely operate the power scooter the documentation does not reveal a home 
assessment to support that the requested device will be able to safely maneuver in the home and access rooms 
for MRADL participation. The documentation does not support that the POV will significantly improve your 
ability to participate in MRADLs and that you will use it in the home. Our physician reviewer found that your 
condition does not meet Medicare criteria for a power scooter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no 
documentation that daily skilled services are required. Provided records do not document a significant decline 
in the patients functional status compared to his recent baseline to necessitate daily inpatient skilled therapy 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision accessory and/or service component (V2797), 
polycarbonate lenses (V2784), deluxe lens feature (D2702) and anti-reflective coating (V2750) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the lens upgrades. You say that you do not understand why you are being billed 
these additional charges. The Plan denied your request. The Plan says this claim was processed correctly; your 
lenses and frames have been covered in full, but additional upgrades are not covered by your vision 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.  
 
Though the Plan offers a supplemental vision benefit in excess of Medicare coverage, the requested items and 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the vision accessory and/or service component (V2797), polycarbonate lenses (V2784), deluxe lens 
feature (D2702) and anti-reflective coating (V2750) provided on November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you have no 
daily skilled nursing or therapy needs. 
 
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 services. Our physician reviewer 
found that you were admitted to the hospital from a nursing facility due to acute renal injury and combative 
behavior. The most recent therapy documentation indicates that you require extensive assistance for mobility 
and self-care tasks due to cognitive impairment. Your cooperation with skilled rehab is limited. You are 
medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or 
near your baseline. Therefore, an admission to a SNF is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 with subdural hematomas. The record indicates that the 
enrollee has ongoing neurologic deficits and requires ongoing critical care services. The enrollee continues to 
receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the charge for provided care between 10PM and 8AM at a 
24-hour facility for services provided on August 4, 2021, billed with code 99053. 
 
You asked the Plan to pay for the overnight care charge as billed. You say that according to Texas state law, 
the Plan must allow an appropriate amount for services rendered. You feel that the allowed amount on this 
claim is not appropriate. You feel that the amount paid should be increased or you will be seeking arbitration 
for additional payment. The Plan denied your request. The Plan says the code 99285 was reimbursed to the 
Medicare-allowable. No separate payment can be made for code 99053. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99053 has a status indicator of "B" in the Medicare Physician Fee Schedule. This means that payment for 
this service is bundled into payment for other services rendered. Based on this information, we decided that 
Medicare rules for coverage of the overnight care charge as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the charge for provided care between 10PM and 8AM at a 24-hour 
facility for services provided on August 4, 2021, billed with code 99053.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5140) provided on August 18, 2021. 
 
You asked the Plan to pay for hearing aids. You say that you did not know you had a hearing aid benefit with 
your plan until after you made this purchase. The Plan denied your request. The Plan says hearing aids are only 
covered when purchased through the specified hearing vendor network. The provider in this case does not 
participate in the required network, therefore, your request for reimbursement is denied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specified models listed in the contract and purchased through the Plans 
specified hearing vendor network.  
 
 We looked at the file and the Plan's rules. The provider in this case does not participate in the Plans hearing 
network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5140) provided on August 
18, 2021.  
 
Your complaint about potential misinformation from a Plan representative regarding your benefits prior to 
services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right prosthetic leg with an advanced foot feature for 
the enrollee.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a K3 functional level foot component does not meet Medicare criteria as 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the physician documentation does not support that the patient is a K3 ambulator; therefore, this request 
exceeds the patient's 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 a right prosthetic leg with an advanced foot feature for the enrollee.