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

 
We decided that the Plan does not have to pay for the refraction provided on October 17, 2022. 
 You asked the Plan to pay for the refraction. You say that this should be covered as a routine eye exam. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 this service when performed as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. 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 provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on May 09, 2022. 
 
You asked the Plan to pay for observation care. You say that it is the responsibility of the facility to obtain 
referrals. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for observation care 
provided on May 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the request for the MyoPro 
Motion G is for the treatment of their right dominant upper extremity partial paralysis since the enrollee 
suffered a stroke in August 2019. The enrollee has tried and failed physical therapy and occupational therapy, 
with modalities of static bracing, as well as Botox injections. This device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested item is not considered medically 
reasonable and necessary in this case. 
 
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 a MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 enrollee. 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement provided on December 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement service. You say that you do not agree with the denial. You also 
say that the service should be paid. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 the nail debridement provided on December 29, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing of each nerve (95937) 
provided on July 14, 2022. 
 
You asked the Plan to pay for the testing of nerve-muscle junction. You say that the claim should be paid as 
billed. The Plan denied your request. The Plan says current procedural terminology (CPT) code 95937 remains 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 the testing of nerve-muscle junction.  Our reviewer says that 
the documentation does not support procedure code 95937.  Our reviewer found the procedure report does not 
provide clear documentation to support the neuromuscular junction testing of each nerve billed was provided. 
In terms of CPT 95937, the record does not contain evidence that a neuromuscular junction testing of each 
nerve was performed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing of nerve-muscle junction have not been met. Therefore, we decided 
that the Plan does not have to pay for the neuromuscular junction testing of each nerve (95937) provided on 
July 14, 2022.
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 you are currently hospitalized and need to transition 
to a SNF due to medical necessity. The Plan denied your request. The Plan says you do not meet the guidelines 
for admission to a SNF. 
 
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 have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not require 
skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of 
service criteria for 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 SNF care.
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 has tried Hexahydro cannabinol (HHC) 
and has had no luck with skilled nursing facility. The enrollee also has been bed ridden due to spinal cord 
injury for over 1 year. The Plan denied your request. The Plan says the enrollee doesnt meet all of the 
requirements. The requirements are: 
(1) enrollee need and can tolerate multiple therapies (such as physical, occupational and others). 
(2) enrollee is able and willing to actively participate and benefit from multiple therapies. And 
(3) enrollee's condition requires management by a physician who specializes in rehabilitation.   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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of congestive heart failure and is living at home with weakness. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. There is not a reasonable expectation that this 
enrollee 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 pre-approve prosthodontics fixed, pontic - porcelain/ceramic 
(D6245). 
 
You asked the Plan to pre-approve prosthodontics fixed, pontic - porcelain/ceramic. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
prosthodontics fixed, pontic - porcelain/ceramic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on October 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The services at issue were provided in an outpatient hospital facility. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on October 24, 2022.
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 you had a traumatic brain injury, and you require 
help doing everything. You also say if you do not go to the IRF, you will not be able to walk. The Plan denied 
your request. The Plan says the requested IRF services are not medically 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 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. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on July 27, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on July 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm (AAA) 
(76706) provided on November 2, 2022. 
 
You asked the Plan to pay for the AAA screening study. You say that this procedure was performed at the 
request of the enrollee's referring doctor, as the enrollee's medical condition proved the medical necessity for 
the service. You also say that the diagnosis code, Z13.6, was assigned to the service based on this indication. 
The Plan denied your request. The Plan says the submitted diagnosis does not indicate the enrollee is included 
in, or received the screening study, for one of the risk categories. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also say that payment may be made 
for a one-time ultrasound screening for abdominal aortic aneurysm (AAA) for beneficiaries who meet the 
criteria listed in the Medicare rules section of this letter. 
 
The test at issue in this appeal, the AAA screening study, was requested solely for screening purposes. Though 
Medicare does not cover this test solely for screening purposes, a one-time ultrasound screening for AAA is 
allowed for beneficiaries who meet the criteria. The record shows that the diagnosis code submitted for this 
screening was Z13.6, defined as Special screening examination for cardiovascular disorders. This diagnosis is 
for screening purposes, and does not show that the enrollee is included in at least one of the risk categories. 
Therefore, we decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm 
(AAA) (76706) provided on November 2, 2022.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the provision related to the numbers of 
inpatient stays/emergency room visits is too restrictive when compared with the Social Security Act language. 
The Plan denied your request. The Plan says that based on the information submitted there is no documentation 
that the enrollee meets criteria. 
 
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. The Plan did not provide a copy of the applicable 2023 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial in this case, or that the enrollee has been adequately 
notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial in 
this case. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).  
 
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 procedure code 99283 billed for date of service July 22, 
2022. You asked the Plan to pay for procedure code 99283. You say that 99283 is a replacement code. The Plan 
denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 
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, we have confirmed that code 99283 is a column II code to column I code 99284. Code 99283 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99283 
billed for date of service July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 10, 2022.