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

 
We decided that the Plan does not have to pay for eyeglasses you purchased from an out-of-network online 
vendor on October 3, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you purchased the eyeglasses online because the 
progressive lenses you needed were less expensive there. The Plan denied your request. The Plan says you do 
not have out-of-network vision benefits. 
 
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 eyeglasses only when purchased from a provider in the Plan's vision vendor network.  
You did not purchase your eyeglasses from a network vendor. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for eyeglasses you purchased from an out-of-network online vendor on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220, 99226 and 99217 billed for August 
20, 2022, to August 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 99220, 99226, 99226, 99226 and 99217 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 99220 is Level 3 initial observation care for evaluation 
and management of patient with problem of high severity, including comprehensive history and physical 
examination, and medical decision-making of high complexity, typical time 70 minutes. The definition of code 
99226 is Level 3 initial observation care for evaluation and management of patient with problem of high 
severity, including comprehensive history and physical examination, and medical decision-making of high complexity, typical time 70 minutes. The definition of code 99217 is observation care discharge day 
management, discharge day subsequent to initial observation day. 
 
We find that CPT codes 99220, 99226 and 99217 are not supported in the medical record. Specifically, the 
records show that the enrollee's status was not designated or admitted for observation status. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99220, 99226 and 99217 billed for August 20, 
2022, to August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge, retainer crowns on tooth numbers 27, 28, 
31 and pontics for tooth numbers 29 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the purpose of the bridge is to provide 
occlusion on the right side and arrest the super eruption of the maxillary dentition. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  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 dental services. Our reviewer says 
that the request does not meet the criteria for coverage. Our physician reviewer found that fixed bridges may be 
considered for coverage to replace a single maxillary anterior tooth or two adjacent mandibular anterior teeth or 
when there is documentation that a removable appliance is contraindicated. In this case there was no 
documentation that a removable appliance could not be used. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge, retainer crowns on tooth numbers 27, 28, 31 and pontics for tooth 
numbers 29 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services (77067, 77063) provided on 
November 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON mammography services. You say that this was medically necessary. The 
Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 mammography services (77067, 77063) provided 
on November 17, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0813). 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says that the 
coverage criteria has not been met and a power operated vehicle evaluation has not been performed. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 
the coverage criteria has not been met. Our physician reviewer found that there is insufficient clinical 
documentation regarding your current level of mobility and ability to perform daily activities. You have a 
manual wheelchair, but it is not clear why you are limited in terms of your ability to propel it for mobility. 
There is limited physical examination findings in terms of your upper and lower extremity strength and range 
of motion. There is also a lack of documentation indicating that you can safely transfer to and from the 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 (K0813).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for skilled nursing 
facility (SNF) care. 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 SNF care is medically necessary because you live at 
home by yourself and are currently unable to do anything without assistance. The Plan denied your request. 
The Plan says the requested SNF services are not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the glasses provided on September 2, 2022. 
 
You asked the Plan to pay more for the glasses. You say that you would like to know why the other $453.42 
was not reimbursed. You also say that these glasses were required because of your cataract surgery. The Plan 
denied your request. The Plan says these services were considered at the contracted rate for your provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you received these glasses from an out-of-
network provider, but the Plan covered their share at the in-network rate. The Plan is not obligated to pay more 
than the contracted rate for services rendered by an out-of-network provider. Based on this information, we 
decided that the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan 
does not have to pay more for the glasses provided on September 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with a specialty compounded drug. 
 
You asked the Plan to pre-approve a specialty compounded drug. You say that the requested treatment is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, the case record confirms that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve treatment 
with a specialty compounded drug.  
 
  Benefits for a specialty compounded drug 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasonic guidance for blood vessel access (76937), provided on 
August 28, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that Medicare rules for payment of this claim have not 
been met. 
 
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. procedure code 76937 is not an add on code. Therefore, we decided that the Plan 
has to pay for an ultrasonic guidance for blood vessel access (76937), provided on August 28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service September 
26, 2022. 
 
You asked the Plan to pay for procedure code A4550. You say that please reconsider and reprocess your appeal 
on the claim for reimbursement. The Plan denied your request. The Plan says procedure code A4550 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0672). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
would face obstacles that would impair healing if forced to use the in-network provider. You request overturn 
of the denial for authorization for the lymphedema pump which the doctor has ordered for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  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. Therefore, we decided that the 
Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic 
appliance (E0672).
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 the enrollee is receiving care for multiple acute 
medical problems including respiratory failure due to pneumonia, hypoxia, and lung cancer. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, outpatient setting or home health care 
 
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 enrollee was admitted to the hospital for acute on chronic respiratory failure with 
pneumonia. The complexity of the patients nursing medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was ambulating 30 
feet with a walker with minimal assistance. The enrollee required minimal assistance for transfers and daily 
activities. The enrollee has had a decline from his baseline level of function and would benefit from therapy but 
does not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infiltration of sustained release therapeutic drug, per 
quadrant (D9613). 
 
You asked the Plan to pre-approve infiltration of sustained release therapeutic drug. You say that this drug will 
help you heal after your extraction. The Plan denied your request. The Plan says this service is not covered 
under your plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
infiltration of sustained release therapeutic drug, per quadrant (D9613).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code 88305-26 billed for date of service August 16, 2022. 
 
You asked the Plan to pay for code 88305-26. You say that this procedure was performed multiple times by 
different providers. The Plan denied your request. The Plan says that this is a duplicate claim/service. 
 
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's sole rationale for denial is that this claim is a duplicate 
and you did not bill with a modifier signifying that a different provider performed the service. The burden is on 
the Plan to show why its denial is appropriate.  The Plan has failed to provide any evidence of a second claim 
(paid or not) that billed this same code.  Without a second claim, we cannot determine if the one at issue in this 
case is a duplicate. Because the Plan has failed to provide this evidence in its case file submission, we find that 
the Plan has not met this burden. Therefore, we decided that the Plan has to pay for code 88305-26 billed for 
date of service August 16, 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 pre-approve driving evaluation services. 
 
You asked the Plan to pre-approve driving evaluation services. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not reimburse evaluations performed 
solely to assess a beneficiary's ability to drive a vehicle. Based on this information, we decided that Medicare 
rules for coverage of driving evaluation services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve driving evaluation services.