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

 
We decided that the Plan has to pay for a second pair of glasses provided on January 10, 2022. 
 
You asked the Plan to pay for a second pair of glasses. You say that this provider told you that you can get two 
pairs of eyewear under the vision allowance. You also say that you are now receiving a bill for the second 
reading pair. The Plan denied your request. The Plan says that you are covered for one pair of eyeglasses with a 
$275 allowance every year. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when supplied by an in-network provider's office. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $275 routine prescription eyewear 
allowance for frames, lenses, contacts, and contact lens fittings when supplied by an in-network provider's 
office. The contract does not say that there is a limit to the quantity of eyeglasses you can purchase. Based on 
this information, we decided that the Plan's rules for coverage of a second pair of glasses have been met. 
Therefore, we decided that the Plan has to pay for a second pair of glasses provided on January 10, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would greatly benefit from intensive 
care in order to return to his baseline. The Plan denied your request. The Plan says based on Medicare 
guidelines, the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 for metabolic encephalopathy, hypercalcemia, 
myocardial infarction, and bacteremia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. Medically necessary care can be provided in a 
different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from May 1, 2022, to  
May 19, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 11, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided from May 1, 2022, to May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Orthovisc, for intra-articular 
injection, per dose (J7324). 
 
You asked the Plan to pre-approve the injection. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the standards have not been met due to other 
treatment options that are being considered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee with a past medical history of hypothyroidism, hyperlipidemia, morbid obesity, 
hypertension, atrial fibrillation, arthritis, esophageal dysphagia who presents for a follow up with continued 
right knee pain. The enrollee has tried Depo-Medrol injection with good success. The enrollee came to discuss 
further treatment of right knee Arthritis and has had significant treatment without success. The enrollee wishes 
to proceed with total knee replacement. The enrollee he was injected with a combination of 80 mg Depo-
Medrol and 9 cc of 1% Xylocaine at the right knee. In this case other treatment options that are being 
considered. The Medicare coverage rule states that coverage of this drug assumes that knee replacement is not 
being considered as a current treatment option. The review has determined that the documentation does not 
support that the Orthovisc is medically reasonable and necessary for the enrollee. The documentation does not 
support that the Orthovisc is safe and effective for the enrollee. The records do not show that the enrollee meets 
the medically necessary criteria for Medicare coverage. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on June 27, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate (J8610). 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says Methotrexate is 
covered under the pharmacy benefit and is not covered under the Medicare medical benefit. 
 
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 Methotrexate (J8610).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 19, 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 code 83789 is 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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
mass spectrometry of non-drug analyte(s). 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 the 
laboratory services rendered on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift recliner provided on December 6, 2021. 
 
You asked the Plan to pay for the lift recliner. You say that the enrollee was unable to rise from a sitting 
position. The Plan denied your request. The Plan says durable medical equipment must be provided through a 
Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lift recliner provided on December 6, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015), contact lens 
fitting for corneal lenses (92310), and a specialist office visit (99203) provided on March 9, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015), contact lens fitting for corneal lenses 
(92310), and a specialist office visit (99203). You say that prior to the member's visit, you called his primary 
care provider's office and requested a referral. You also say that you were told there was no referral necessary 
by the provider's office. The Plan denied your request. The Plan says services from non-participating providers 
are not covered unless preauthorized. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received by an in-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a determination of refractive state (92015), contact lens fitting for corneal lenses (92310), and a 
specialist office visit (99203) have not been met. Specifically, services from an out-of-network provider are not 
covered. Therefore, we decided that the Plan does not have to pay for a determination of refractive state 
(92015), contact lens fitting for corneal lenses (92310), and a specialist office visit (99203) provided on March 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on April 21, 
2022. 
 
You asked the Plan to pay for the cardiovascular genetic testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. Cardiovascular risk assessment panels are only covered for certain 
indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. In addition, the services rendered are not of those that are covered 
for cardiovascular disease screening. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve Euflexxa injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via 
intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary 
when the patient has failed at least three months of conservative therapy. 
 
We looked at the file and Medicare rules. The submitted medical records do not document that the enrollee has 
failed at least three months of conservative therapy. Based on this information, we decided that Medicare rules 
for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Euflexxa injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the routine frames and lenses (V2020, V2781, V2750, V2784) provided 
March 26, 2022, up to the Plans $175 allowance. 
 
You asked the Plan to pay for the routine frames and lenses. You say that you don't feel your benefit should be 
applied towards a contact lens fitting you never wanted. The Plan denied your request. The Plan says that you 
have exhausted your eyewear 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. The Plan covers these services up to a $175 allowance. 
 
We looked at the file and the Plan's rules. In this case there is no evidence provided showing that the 
supplemental eyewear allowance has been previously applied to contact lenses or eyeglasses and frames. Based 
on this information, we decided that the Plan's rules for coverage of the routine frames and lenses have been 
met. Therefore, we decided that the Plan has to pay for the routine frames and lenses (V2020, V2781, V2750, 
V2784) provided March 26, 2022, up to the Plans $175 allowance.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a gastrointestinal panel provided to the enrollee on March 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that a review of the medical records indicates that C. difficile was not included in the panel under 
review. 
 
The Plan must follow Medicare rules. The rules say that when there is a clinical concern for Clostridium 
difficile colitis, Medicare will cover up to 11 targets if Clostridium difficile is one of the organisms tested for. 
 
The records show that on March 10, 2022, specimens were collected for C. difficile, as well as 
Giardia/Crytosporidium and enteric pathogens. As C. difficile was tested for, the plan's denial is not 
substantiated in this case. Based on this information, we decided that Medicare rules for coverage of the 
services have been met. Therefore, we decided that the Plan has to pay for a gastrointestinal panel provided to 
the enrollee on March 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on March 22, 2022. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says payment for these services cannot be made. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower extremity prosthesis, endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (L5856) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or 
without adjustability (L4848) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable. 
(L5845) addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828). 
 
You asked the Plan to pre-approve Ottobock Kenevo microprocessor knee. You say that you have researched 
about prosthetic legs and read the Medicare criteria and you know you meet the criteria. The Plan denied your 
request. The Plan says the requested Kenevo microprocessor knee exceeds the enrollee's need and is not 
reasonable and necessary per Medicare criteria.  
 
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 Ottobock Kenevo microprocessor knee. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested microprocessor knee has features such as intuitive use of 
a stationary indoor bicycle, adjustments from a smartphone with the Cockpit app, and convenience features of 
charging without removing the foam cover per an online review of this knee 
(https://www.ottobockus.com/media/localmedia/prosthetics/lowerlimb/kenevo/ottobock_mpk_b2c_bro_0621_
19439.pdf). The physician documentation does not reveal that the enrollee  requires a microprocessor knee over 
a K3 mechanical knee particularly given the additional weight of the requested microprocessor knee and the 
enrollees comorbidities. The requested Kenevo knee has deluxe features which are not medically necessary for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ottobock Kenevo microprocessor knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the addition to lower extremity prosthesis, endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (L5856) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or 
without adjustability (L4848) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable. 
(L5845) addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828).