Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to 
the enrollee on August 17, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this should be paid for. The Plan 
denied your request. The Plan says denied your request. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a pneumatic compression device have not been met. Specifically, the requested device (E0675) and 
accessory (E0673) are statutorily not covered by Medicare. Therefore, we decided that the Plan does not have 
to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate dressings provided on November 16, 2020, 
billed with code A6197. 
 
You asked the Plan to pay for the alginate dressings. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a payable code for a physician claim. 
 
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 A6197 has a status indicator of "P" on the Physician Fee Schedule. This means that no separate payment 
can be made for this code on the fee schedule. This code is a payable only to a Durable Medical Equipment 
(DME) suppler. Based on this information, we decided that Medicare rules for coverage of the alginate 
dressings have not been met. Therefore, we decided that the Plan does not have to pay for the alginate dressings 
provided on November 16, 2020, billed with code A6197.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture (D5226) provided on October 25, 
2021. 
 
You asked the Plan to pay for the lower partial denture (D5226). You say that you never received a more recent 
publication of your insurance coverage and the 2019 plan materials clearly show dentures are covered at 50%. 
You say that you authorized the dentist to proceed based on the information provided and the claim should be 
reconsidered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the lower 
partial denture (D5226) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network retinal ophthalmologist. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network retinal ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction you received on August 25, 2020. 
 
You asked the Plan to pay for the refraction. You say that the refraction should be covered as part of the eye 
exam you had. The Plan denied your request. The Plan says your vision benefits only entitle you to one 
refraction per year as part of a routine eye exam.  The refraction you received on August 25, 2020, was not 
performed as part of a routine eye exam. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
refractions as part of a routine eye exam.  In this case, the records show that on August 25, 2020, you did not 
have a routine eye exam.  Rather, the doctor that you saw billed for a comprehensive diagnostic eye exam for 
the diagnosis of bilateral hypermetropia.  This is not the same thing as a routine eye exam. A routine eye exam 
is done for check vision and screen for eye disease, not to evaluate a current eye condition. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction you received on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the crown (code D2750) you received on 
July 14, 2021. 
 
You asked the Plan to waive the copayment for the crown. You say that you were never told about this 
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment per tooth for crowns.  
 
You have been asked to pay a $125 copayment per tooth for the crown. 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 the crown (code D2750) you received on July 14, 2021.
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 it is not necessary to provide these skilled 
nursing or skilled therapy services, or a combination of these services, on a daily basis. 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: 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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous. Transfer to a lower level of care may be considered soon when treatment has 
completed. 
 
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: 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 documentation does not support that it is 
medically reasonable and necessary to provide skilled therapy services) on a "daily basis" 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on April 5, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare for review prior to the Plans review. 
Once Original Medicare submits an explanation of benefits concluding their review, the Plan can review for 
any further coverage. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He 
has not tried and failed the Plan's required drugs, Orthovic, Supartz FX, Durolane, Monovisc, or Synvisc-One. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 
is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
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 this is medically necessary. The Plan denied your 
request. The Plan says IRF care is not medically reasonable and necessary. 
 
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 review indicates that the complexity of your nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for China-Gel topical pain reliever herbal therapeutic massage 
cream you purchased on December 16, 2021, under your Pick Your Perks benefit. 
 
You asked the Plan to pay for the China-Gel cream. You say that the Plan has paid for this item in the past, so 
it should be covered. The Plan denied your request. The Plan says China-Gel is not a covered item under the 
Pick Your Perks benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that generally Medicare does not cover over-the-
counter (OTC) items, but Plans may cover them as a supplemental benefit.  Your Plan offers an OTC benefit 
beyond Medicare coverage, so the Plan's coverage rules apply.  In this case, your Plan's OTC benefit explicitly 
excludes coverage for herbal OTC items.  The China-Gel cream you purchased is labeled as an herbal 
therapeutic massage cream. Therefore, this item is explicitly excluded from coverage, regardless of whether or not is has be paid by the Plan in the past.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the China-Gel cream have not been met. Therefore, we decided that the Plan does not have to pay 
for China-Gel topical pain reliever herbal therapeutic massage cream you purchased on December 16, 2021, 
under your Pick Your Perks benefit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
chest and spine provided on September 23, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that this extra MRI should be including with 
your original appointment. You say that it was not your fault that one of the tests had to be rescheduled. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $100 
copayment for advanced imaging services, including MRI's.  
 
You have been asked to pay a $100 copayment for the MRI. The MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 magnetic resonance imaging (MRI) of the chest and spine provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for specialist office visits and 
a diagnostic ear and nose exam provided on July 20, 2021, and September 15, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the specialist office visits and exam. You say 
that you were not aware that you would be responsible for the remaining amount that the Plan did not pay. The 
Plan denied your request. The Plan says the correct copayment and coinsurance was applied. 
 
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 $40 
copayment for each in-network specialist visit.  
Your contract with the Plan also clearly says that you must pay a 35% coinsurance for each out-of-network 
specialist visit. 
 
Service Allowed Amount Copayment/35% Coinsurance 
Office Visit  July 20, 2021 - $40 (copayment) 
Office Visit  September 15, 2021 $125.78 $44.02 
Ear/Nose Exam  September 15, 2021 $28.61 $10.01 
Total:  $94.03 
 
The file shows that the Plan approved the first visit at the in-network rate, but the second was not. Therefore, 
you have been asked to pay $94.03 for the specialist office visits and exams. The specialist office visits and 
exams fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment and coinsurance for specialist office visits and a diagnostic ear 
and nose exam provided on July 20, 2021, and September 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services (97110) provided on September 16, 
2021. 
 
You asked the Plan to pay for the therapeutic services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapeutic services (97110) provided on 
September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for routine vision services, frames, and progressive lenses you 
received from an out-of-network vision care provider on November 15, 2021. 
 
You asked the Plan to pay for the routine vision services, frames, and progressive lenses. You say that you do 
not understand why this provider is charging you. The Plan denied your request. The Plan says routine vision 
care is only covered when you use a network 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. The Plan covers these services when received from a network optical provider. 
 
We looked at the file and the Plan's rules. The Plan only covers routine vision items and services when received 
from a network optical provider. You did not use a network optical provider. Based on this information, we 
decided that the Plan's rules for coverage of the routine vision services, frames, and progressive lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for routine vision services, frames, and 
progressive lenses you received from an out-of-network vision care provider on November 15, 2021.