Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the cataract surgery performed by an in-
network provider on November 10, 2022. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that you were not aware of the 
extra cost sharing for this service. The Plan denied your request. The Plan says this cost sharing was charged 
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 says that you must pay the full cost for 
most covered services until you have paid the $1000 deductible, and the deductible applies to in-network 
outpatient surgery services. Your contract with the Plan also says that you must pay a $395 copayment after the 
$1000 deductible, for each in-network Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a cost share of $1395 for the cataract surgery ($1000 deductible + $395 copayment 
= $1395). The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible 
which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. This cost sharing is a contractual obligation that had not been met at the time the cataract 
surgery was performed on November 10, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for the cataract surgery performed by an in-network provider on November 10, 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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hereditary CGx Comprehensive Complete Cancer Panel 
billed with codes 81162, 81201, 81218, 81292 81295, 81298, 81307, 81317, 81321, 81351, 81209 81314, 
81334, 81345, 81272, and 81279 provided on November 15, 2022. 
 
You asked the Plan to pay for the Hereditary CGx Comprehensive Complete Cancer Panel. You say that this 
testing will help in choosing the right cancer treatment for the enrollee. The Plan denied your request. The Plan 
says the testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components.  
We looked at the file and Medicare rules. The test panel is a single test with multiple components and is 
characterized by a single unit of service (UOS = 1). A panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. Based on 
this information, we decided that Medicare rules for coverage of the Hereditary CGx Comprehensive Complete 
Cancer Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Hereditary 
CGx Comprehensive Complete Cancer Panel billed with codes 81162, 81201, 81218, 81292 81295, 81298, 
81307, 81317, 81321, 81351, 81209 81314, 81334, 81345, 81272, and 81279 provided on November 15, 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 a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs related to their comorbidities and allow the enrollee the opportunity to 
regain prior level of functioning to improve their quality of life. The Plan denied your request. The Plan says an 
IRF admission is 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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollees medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee 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 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TechShield Elite UVR coating provided on October 28, 
2022. 
 
You asked the Plan to pay for the TechShield Elite UVR coating. You say that you were overcharged for the 
eyeglasses. You say you should be reimbursed. The Plan denied your request. The Plan says the service was 
not a covered 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 does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, this service is not listed as a covered benefit. Based on 
this information, we decided that the Plan's rules for coverage of the TechShield Elite UVR coating have not 
been met. Therefore, we decided that the Plan does not have to pay for the TechShield Elite UVR coating 
provided on October 28, 2022.  
 
Your complaint about improper billing 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services and an electrocardiogram provided 
on February 14, 2022. 
 
You asked the Plan to pay for emergency room services and an electrocardiogram. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
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 emergency room services and an electrocardiogram provided 
on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert or alarm device (A9280). 
 
You asked the Plan to pre-approve an alert device. You say that you are at risk for falling. You also say that 
this is medically necessary for you. The Plan denied your request. The Plan says the requested device is not 
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 an alert or alarm device (A9280).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair stair lift (A9270). 
 
You asked the Plan to pre-approve stair lift. You say that the enrollee lives in a two-story home. You say that 
the enrollee needs assistance to get down the stairs. You also say that due to the enrollee's medical history, they 
are unable to feel their legs. The Plan denied your request. The Plan says items for convenience are not a 
covered benefit. 
 
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 a chair stair lift (A9270).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary and should be 
covered. The Plan denied your request. The Plan says there are other in-network sleep study facilities that are a 
short distance from your residence. 
 
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 sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the Plan's denial of 
this benefit. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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 you are below baseline and unable to manage stairs 
to allow therapists inside. You live alone and it is unsafe for you to be home alone at this time. The Plan denied 
your request. The Plan says the services you require can safely be received at a different setting such as home 
with home health, in residential care, or home with close follow-up with your doctor. 
 
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 daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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. The Plan denied your request. The Plan says that based on 
no information submitted, there is no documentation that you meet all three 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. Specifically, the records do not support that the Plan made multiple attempts to 
obtain medical records from the provider for this case. This means that the Plan has not provided a valid reason 
for denying payment of the SSBCI benefits. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) and implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve dental services. You say that you were led to believe implants would be 
covered. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Custom fabricated abutment  
includes placement (D6057) and implant supported porcelain/ceramic crown (D6065) are not covered under the 
Plans dental benefits 
 
  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 
custom fabricated abutment  includes placement (D6057) and implant supported porcelain/ceramic crown 
(D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the chiropractic services provided from 
September 9, 2021, to September 27, 2021. 
 
You asked the Plan to waive the copayments for the chiropractic services. You say that you are on a fixed 
income and cannot afford these payments. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $15 
copayment for each Medicare-covered chiropractic visit.  
 
You have been asked to pay a $15 copayment for each chiropractic visit. You have been asked to pay a total of 
$75 ($15 copayment per visit x 5 visits = $75). These items/services fall within the chiropractic services 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 copayments for the chiropractic services provided from 
September 9, 2021, to September 27, 2021.
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 the enrollee cannot live in their home and receive 
home health care. The Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on March 8, 2022, and 
March 9, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99233 is included in the global surgery 
payment for procedure code 44970 provided on March 9, 2022. Separate payment cannot be made for 
procedure code 99233. The records provided do not support the use of modifier 24 with code 99233 as an 
unrelated evaluation and management service by the same physician during a postoperative period. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99233 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99233 provided on March 8, 2022, 
and March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these are not covered items. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial 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 the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675, E0673).