Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 28, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you received a 
medical eye refraction for the diagnosis of combined forms of age-related cataract, right eye. Per the 2022 
Evidence of Coverage, Chapter 4, page 106-109, it states eye refractions are only covered by your Plan if 
performed by a participating provider and performed as a routine screening. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on January 28, 2022.
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 the 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee is mobilizing household distances w/ 
minimal assistance. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that your needs can be met at a lower level of care 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88307, 88311) provided October 21, 
2021. 
 
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88307 & 88311 is not supported in the medical record. Specifically, claims 
21M552294601 and 22B191753900 are exact duplicates. The records only support one unit of each service. 
Based on this information, we decided that Medicare rules for coverage of the pathology services have not been 
met. Therefore, we decided that the Plan does not have to pay for pathology services (88307, 88311) provided 
October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 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 March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87505) provided December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The records do not show that the service was ordered by the treating 
physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (87505) provided 
December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter (K0823) provided September 23, 2021. 
 
You asked the Plan to pay for the power scooter. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the claim was billed with an inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code K0823 is not supported in the medical record. Specifically, the KJ modifiers were 
incorrectly billed for the capped rental item. Based on this information, we decided that Medicare rules for 
coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to pay for 
a power scooter (K0823) provided September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 28, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted medical records to 
support payment of this code. The Plan denied your request. The Plan says no separate payment is made for 
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.  
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service January 28, 2021.
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program 
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 8 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT sessions. You say that you feel that you still need to make 
more progress before you can discontinue PT. The Plan denied your request. The Plan says that you have 
received the improvement you required from the amount of therapy provided. No further therapy is needed at 
this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the additional PT sessions. Our 
reviewer says that the additional therapy being requested is shown to be medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a 58-year-old male with a history of cauda equina 
syndrome, radiculopathy, and meningitis with low back and hip pain, as well as balance impairment. The 
enrollee has completed 20 PT sessions thus far. 
 
Clinical documentation by the physical therapist and provider state that the etiology of the balance impairment 
and weakness is due to complex neurological impairments. Therapy goals both short and long term are listed, 
and the patient has not met all goals; thus, 8 additional physical therapy sessions are reasonable and medically 
necessary. Due to complex functional impairments, treatment was not documented as being stable for a home 
exercise plan and would require the skill of a professional therapist to continue.  
 
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 additional PT sessions have been met. Therefore, we decided that the Plan 
has to pre-approve an additional 8 physical therapy (PT) visits.  
 
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 pay for the hearing aid you purchased from an out-of-network 
provider on January 31, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you were told that out-of-network hearing aids 
would be covered. The Plan denied your request. The Plan says you purchased this hearing aid from an out-of-
network provider, so it is not covered. The Plan also provided phone records showing that you were advised 
that hearing aids would only be covered if you used the Plan's designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received from the Plan's designated hearing aid vendor.  You did not use the Plan's 
designated hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid you 
purchased from an out-of-network provider on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) for a medical diagnosis provided 
on March 14, 2022. 
 
You asked the Plan to pay for the medical eye refraction. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says Medicare does not pay for eye refraction 
services for a medical diagnosis. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. The Plan only covers eye refractions as part of a routine exam. The file shows you received the eye 
refraction for a medical diagnosis. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) for a medical diagnosis provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 these services was not filed until December 30, 2021. A valid Waiver of 
Liability (WOL) was not received until March 11, 2022. 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 laboratory services rendered on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus for the enrollee. 
 
You asked the Plan to pre-approve Ocrevus. You say that this is medically necessary. The Plan denied your 
request. The Plan says that in order for them to cover this drug, you must have tried and failed treatment with 
glatiramer (Copaxone) or dimethyl fumarate (Tecfidera). 
 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 Ocrevus. Our reviewer says that 
Ocrevus is not medically reasonable and necessary. The Plan requires a trial of glatiramer (Copaxone) or 
dimethyl fumarate (Tecfidera) before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found 
that the enrollee's condition does not meet step therapy criteria for Ocrevus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections, single or multiple trigger points, 1 or 2 
muscles (20552) injections, single or multiple trigger points, 3 or more muscles (20553). 
 You asked the Plan to pre-approve the trigger point injections. You say that please see the additional records 
and MRI. The enrollee does have radiating pain. The Plan denied your request. The Plan says the records do 
not show that the enrollee meets the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the trigger point injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is a lack of clear documentation, which is required, as to where this 
trigger point or points are. Therefore, at this time, the request is considered 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 trigger point injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve injections, single or multiple trigger points, 1 or 2 muscles (20552) 
injections, single or multiple trigger points, 3 or more muscles (20553).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided March 7, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you thought it would lower cost and risk 
of COVID germs to stay home instead of being transported to the hospital. The Plan denied your request. The 
Plan says ambulance services are not covered when you are not transported. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on January 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided March 7, 2022.
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 it is medically necessary for acute care 
services and the LTACH is medically appropriate. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and does not require tranfer to a LTACH. 
 
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 patient appears to be more stable and improving and should only require short-
term additional acute care services that can safely be completed at the current facility until more appropriate for 
a lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) and administration 
(90471) provided on November 5, 2021. 
 
You asked the Plan to pay for a Zoster vaccine and administration. You say that you cannot afford this charge. 
The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your prescription 
drug plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Zoster vaccine and 
administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Zoster vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine 
(90750) and administration (90471) provided on November 5, 2021.  
 
Benefits for a Zoster vaccine and administration 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy services provided from January 30, 2021, to 
May 19, 2021. 
 
You asked the Plan to pay for massage therapy. You say that these services were very beneficial for you and 
should be covered. The Plan denied your request. The Plan says massage therapy is not covered by Medicare or 
your Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy services provided from January 30, 2021, to 
May 19, 2021.