Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were paid for previous services. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 provided on September 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service May 10, 
2022. 
  You asked the Plan to pay for procedure code 20930. You say that the service was medically necessary. You 
say that the medical records should be reviewed, and the claim reconsidered for payment. The Plan denied your 
request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on June 21, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you did not know this provider was 
out-of-network and cannot afford to pay this amount. 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. Your 
contract with the Plan says that there is a $233 deductible which applies to physician/practitioner services. 
Your contract with the Plan also says that you then must pay a $0 copayment after meeting the deductible for 
in-network office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $233 deductible which applies to physician/practitioner services. This cost sharing is a contractual 
obligation that had not been met at the time the office visit was received on June 21, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for the office visit provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy (code 97802) provided on 
November 1, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this service does not meet the coverage requirements in 
the applicable National Coverage Determination (NCD). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy provided on November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses (V2781) provided on November 8, 
2022. 
 
You asked the Plan to pay for the progressive lenses. You say that you believe the amount you were 
reimbursed was too little, and you would like to be paid more than $159.00. You also say that you are not 
looking for the Plan to pay for the lenses, but a little more for the frames. The Plan denied your request. The 
Plan says this claim processed correctly in accordance with your 2022 Evidence of Coverage. The Plan also 
says that progressive lenses are not covered by Medicare. 
 
 
 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 standard frames and lenses for cataracts up to the Medicare allowed amount. 
 
We looked at the file and the Plan's rules. Specifically, you received progressive lenses, which are considered 
an upgrade, and are not covered by the Plan. The record also shows that you were reimbursed in full for the 
frames. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have 
not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) 
provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) billed on September 2, 
2022, and September 3, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that procedure code 99233 should be 
paid. The Plan denied your request. The Plan says the billed services are not supported. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 subsequent hospital care (99233). Our reviewer says that 
procedure code 99233 is not supported in the documentation. Our reviewer found that the examination and 
history were focused and not detailed. The enrollee was stable and medical decision-making was not described 
as high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care (99233) have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital care (99233) billed on September 2, 2022, and September 
3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 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 Trulicity.  
 
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize his level of functioning prior to returning home. The Plan denied your request. The 
Plan says the enrollee does not meet the requirements for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy 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 
inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that the 
enrollee would meet criteria for admission to 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 You asked the Plan to pre-approve IMRT. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is covered for the indications established in the 
applicable LCA. 
 
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 IMRT. Our reviewer says that IMRT is 
not medically reasonable and necessary in this case. Our physician reviewer found that given that the enrollees 
tumors are in the lung, the provided records in this case do not clarify that the enrollee has unique medical or 
physical characteristics for which conventional radiation therapy would be unacceptable, or that the enrollee 
has already received a maximum amount of radiation delivered by conventional means to meet criteria for 
IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 2, 2022, to 
January 31, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the NOA and would 
like this claim paid. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 2, 2022. The NOA was not received by the Plan until March 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 2, 2022, to January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (28755, 28300) provided on April 13, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 28755 & 28300 are arthrodesis of the interphalangeal 
joint on the great toe and an osteotomy of the calcaneus. 
 
We find that CPT code 28755 & 28300 is not supported in the medical record. Specifically, the operative report 
does not document that these procedures were performed. Based on this information, we decided that Medicare 
rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have 
to pay for surgical services (28755, 28300) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye injections to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON eye injections. You say that you need these injections. The Plan 
denied your request. The Plan says these injections are available 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 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 
eye injections to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have pain in your right shoulder. You have received 
treatment for at least four months with little change over the past month. You are able to maintain or improve 
your function with a home exercise program. Continued physical therapy is not reasonable or medically 
necessary based on the submitted records. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a Botox injection. 
 
You asked the Plan to pre-approve a Botox injection. You say that a Botox injection is medically necessary. 
The Plan denied your request. The Plan says that the requested Botox injection 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 a Botox injection. Our reviewer says 
that the requested Botox injection is medically necessary in this case. Our physician reviewer found based on 
standard of care and the literature listed below a Botox injection is medically necessary: 
 
Ennis D, Ahmad Z, Anderson MA, Johnson SR. Botulinum toxin in the management of primary and secondary 
Raynaud's phenomenon. Best Pract Res Clin Rheumatol. 2021 Sep;35(3):101684. doi: 
10.1016/j.berh.2021.101684. Epub 2021 May 5. PMID: 33965340. Gallegos JE, Inglesby DC, Young ZT, 
Herrera FA. Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon. J Hand Surg Am. 2021 
Jan;46(1):54-59. doi: 10.1016/j.jhsa.2020.07.009. Epub 2020 Sep 16. PMID: 32948347. Segreto F, Marangi 
GF, Cerbone V, Persichetti P. The Role of Botulinum Toxin A in the Treatment of Raynaud Phenomenon. Ann 
Plast Surg. 2016 Sep;77(3):318-23. doi: 10.1097/SAP.0000000000000715. PMID: 26808752. 
 
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 Botox injection have been met. Therefore, we decided that the Plan has to pre-
approve a Botox injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that with their need for increased monitoring, 
continued BiPAP weaning, long term antibiotic treatment, complex wound care, and daily physician 
involvement, the enrollee has been referred to LTACH. The Plan denied your request. The Plan says the 
request is not medically necessary because the enrollee is receiving the care they need in the hospital where 
they are now and there is no need to transfer to the LTACH at this time. The enrollee can stay in the hospital 
until they are safe for transfer or discharge. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that the device is an appropriate intervention. The Plan 
denied your request. The Plan says the clinical effectiveness has not been demonstrated. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for dialysis treatment provided from August 23, 2022, 
to August 27, 2022, in Aruba. 
 
You asked the Plan to reimburse you for the dialysis treatment. You say that you must have dialysis treatment 
three days each week due to end stage renal disease and while you were on vacation you required this 
treatment. The Plan denied your request. The Plan says your Plan excludes coverage for scheduled, non-
emergent services while out of the United States. 
 
The contract with the Plan provides coverage for worldwide emergency and urgent care services outside of the 
United States. Pre-scheduled and/or elective procedures are not covered.  
 
We looked at the file and the Plans rules. The file shows the dialysis treatment was pre-scheduled and/or 
elective. The Plan says pre-scheduled and/or elective procedures outside of the United States are not covered. 
Therefore, we decided that the Plan does not have to reimburse you for dialysis treatment provided from 
August 23, 2022, to August 27, 2022, in Aruba.