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

We decided that the Plan does not have to pay for the contact lens, hydrophilic, bifocal (V2522) provided
September 20, 2021.
You asked the Plan to pay for the contact lenses. You say that you were given conflicting information in your
denials. The Plan denied your request. The Plan says you have exceeded the frequency limit for contacts.
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 once every two calendar years.
We looked at the file and the Plan's rules. The Plan provided documentation showing that contact lenses were
previously covered on August 4, 2020. Based on this information, we decided that the Plan's frequency limit
for coverage of the contact lenses has been exceeded. Therefore, we decided that the Plan does not have to pay
for the contact lens, hydrophilic, bifocal (V2522) provided September 20, 2021.
Your complaint about receiving conflicting information from the Plan is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat elevation system (E2300).
You asked the Plan to pre-approve the seat elevation system. You say that the item is medically necessary. The
Plan denied your request. The Plan says this item does not serve a primary medical purpose and is statutorily
non-covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid flow or fluid GF, 1 cc (Q4206) to be provided by
an out of network provider.
You asked the Plan to pre-approve the injection service. You say that per Medicare guidelines, this is an
approved service. Being that this is a Medicare advantage Plan, all Medicare covered services should be
processed and reimbursed. The Plan denied your request. The Plan says this service has not been proven to be
safe and effective and is not considered standard of care. Enrollee's must receive their medical services from an
in-network provider. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are 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 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the injection service have not been met. Therefore, we decided that the Plan does not have to pre-
approve Fluid flow or fluid GF, 1 cc (Q4206) to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve a CT scan of the chest. You say that the CT scan is medically necessary.
The Plan denied your request. The Plan says the CT scan is not medically necessary as there is no nodule
greater than 6 millimeters in diameter.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 a CT scan of the chest. Our reviewer
says that a CT scan of the chest is not medically necessary at this time. Our physician reviewer found that
nodules less than 6 millimeters have optional need for follow-up in 12 months in high-risk patients. A followup
CT at 6 months does not meet Medicare criteria.
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 CT scan of the chest have not been met. Therefore, we decided that the Plan
does not have to pre-approve a computed tomography (CT) scan of the chest
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of the pelvis provided on February 22, 2021, billed
with code 72190.
You asked the Plan to pay for the x-ray as billed. You say that this should be paid due to medical necessity.
The Plan denied your request. The Plan says the imaging report does not support the billing of this code.
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 72190 is Radiologic examination, pelvis; complete,
minimum of 3 views.
We find that CPT code 72190 is not supported in the medical record. Specifically, the imaging report clearly
states that only two views of the pelvis were performed. Based on this information, we decided that Medicare
rules for coverage of the x-ray as billed have not been met. Therefore, we decided that the Plan does not have
to pay for the x-ray of the pelvis provided on February 22, 2021, billed with code 72190.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the pelvis.
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is needed for guidance prior to a robotic arthroplasty total hip surgery. The Plan denied your request. The Plan says they do not see in the notes why the CT scan is being requested. The Plan says that they do not see what the provider is trying to rule out with the CT scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was being treated for pain in unspecified hip, primary osteoarthritis of right hip. She presented with right hip pain with popping/cracking multiple times a day. The pain shoots down her thigh. The pain is worse with walking, internally rotating her hip, going from sitting to standing, getting in/out of a car, and even at rest. Exam reveals flexion from 0 to 110 degrees, external rotation 30, internal rotation 10, abduction 40, and adduction 20. There is a positive Stinchfield sign. X-rays demonstrate moderate to severe right hip, moderate left hip osteoarthritis, no fracture. She has been planned for a total hip arthroplasty. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the requested robotic assisted total hip surgery to be an effective and/or safe treatment for the noted pathology. Large volume long term literature is not evident and or doesn't reveal significant improvement in long-term outcomes regarding pain relief and/or functional improvement (vs. non-
robotic assisted). As the computer assisted procedure is not supported, the need for the preoperative imaging is also not indicated. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for CT scan for guidance prior to a robotic arthroplasty total hip surgery is not medically reasonable or 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the pelvis
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide visits (G0156) for 3 hours, daily.
You asked the Plan to pre-approve home health aide visits. You say that you live alone, with no family. You
say that you live on the third floor. You also say that you need help daily. The Plan denied your request. The
Plan says the additional home health services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve home health aide visits. Our reviewer
says that the requested home health aide services are not medically necessary. Our physician reviewer found
the provided documentation does not indicate the enrollee has documented skilled nursing needs. The reviewer
found that the enrollee does not have documented skilled therapy needs. Therefore, the reviewer found that the
home health aide services are not shown to be medically necessary or reasonable to aide in the treatment of
illness or injury.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide visits have not been met. Specifically, the file does not
indicate that the enrollee requires skilled services. Therefore, we decided that the Plan does not have to pre-
approve home health aide visits (G0156) for 3 hours, daily.
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 enrollee exceeds the Medicare
defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says the
guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in
the current hospital setting.
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 the enrollee was admitted following a cardiac arrest and suffered an anoxic brain
injury. The record indicates that she is still critically ill with neurologic impairment and requires critical care
services. The enrollee continues to receive acute care services, and these have not been denied. The medical
record does not indicate that the enrollee requires services that she is not currently receiving but that would be
available at the LTACH 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, the enrollee does not have a cancer diagnosis. The requested genetic testing in this case
is not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve a targeted genomic sequence analysis panel.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jakafi for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Jakafi for the enrollee.
Benefits for this 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged services (99357) provided on September 14, 2021.
You asked the Plan to pay for prolonged services. You say that this was an emergency service. The Plan denied
your request. The Plan says this was not billed correctly.
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 99357
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for prolonged services (99357) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on October 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the doctor's office should have obtained authorization. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on October 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastroenterology services provided on October 12, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that you had a follow-up visit for your
colonoscopy. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved
in advance.
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 had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the gastroenterology services provided on October 12, 2021, by an out-of-
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on July 19,
2021, to July 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that everything should have been covered. The
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 outpatient mental health services provided on July 19, 2021, to July 29,
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second level for transforaminal epidural injections
(64484).
You asked the Plan to pre-approve the second level. You say that this is medically necessary. The Plan denied
your request. The Plan says the separate request for injections cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the second level. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the request is for two levels of bilateral transforaminal epidural steroid injection. The health
plan has approved one level of bilateral transforaminal epidural steroid injections. The request for a second
level bilaterally exceeds utilization limits and therefore, the request for a second level is not considered
medically reasonable or 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 the second level have not been met. Therefore, we decided that the Plan does
not have to pre-approve a second level for transforaminal epidural injections (64484).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on March 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the service was performed out of medical necessity. The Plan denied your request. The Plan says services must be provided in-network to be eligible for payment.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on March 23, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance
transportation (A0429) provided on May 7, 2019.
You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that you
were not late in submitting the claim, it was due to the technical and system issue for which you were late in
submitting the claim. You also say that you would like this claim to be reconsidered for payment based on
medical necessity. The Plan denied your request. The Plan says the first notice of this claim was received on
May 26, 2021. The Plan also says that your claim was filed outside of the timely filing period, and you have
not supplied any additional information that supports a reversal of the Plan's initial decision.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the ground mileage and emergency ambulance transportation was not filed
until May 26, 2021. This means that more than one calendar year from the date of service had passed before a
claim was filed. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and
emergency ambulance transportation (A0429) provided on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and
management of an established patient (99213) provided on September 3, 2021, by an out-of-network (OON)
provider.
You asked the Plan to pay for the office visit. You say that you should only be charged a $40 copayment. The
Plan denied your request. The Plan says this service is not covered because it was obtained OON.
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 the office or other
outpatient visit for the evaluation and management of an established patient (99213) provided on September 3,
2021, by an out-of-network (OON) provider.