Persius/hicric huggingface dataset:
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 believe you still meet Medicare criteria to 
receive SNF care since a new year has started and your benefits start new. The Plan denied your request. The 
Plan says that your inpatient stay has reached the 100-day benefit limit for this admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from August 30, 2022 to 
February 4, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. 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's medical condition would benefit from 
IRF to improve mobility and regain strength. The Plan denied your request. The Plan says the medical 
conditions are stable and shows the enrollee is not expected to improve a lot in a short period of time. The 
medically necessary care may be provided safely in a different 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 the therapy notes do not show or make any recommendation that the enrollee would 
be able to tolerate 15hrs of therapy per week, IRF criteria not met.  
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the vision services provided on July 26, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that this 
service is excluded from coverage. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The file shows that a posterior chamber intraocular lens (V2632) was provided. The services at issue were 
provided by a contract provider. The file does not show that the Plan provided notice that the services provided 
would not be covered. Under Medicare rules, this means the services provided is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the vision services provided on July 26, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited bilateral noninvasive physiologic study of upper or 
lower extremity arteries (93922) provided on April 5, 2021. 
 
You asked the Plan to pay for a limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says 
corrected claims must be submitted within 1 year from the date of the initial determination or redetermination 
for any reason. 
 
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 a limited bilateral noninvasive physiologic study of upper or lower extremity 
arteries was not filed until July 28, 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 a limited 
bilateral noninvasive physiologic study of upper or lower extremity arteries (93922) provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for treatment with Synvisc One (J7325) 
provided on November 18, 2022. 
 
You asked the Plan to waive the coinsurance for Synvisc One. You say that you have received previous 
treatment with Synvisc-One and never had a charge applied. 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 20 
percent coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $93.79, or 20 percent of the Medicare-allowed charge of $468.96, for Synvisc 
One. This item/service falls within the Medicare Part B prescription drugs 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 coinsurance for treatment with Synvisc One (J7325) provided on November 18, 
2022.   
Your complaint about having been billed incorrectly for prior treatments with Synvisc One 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: 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 the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 services are necessary for the enrollee to rebuild 
strength and endurance to maximize recovery and return to independence. The Plan denied your request. The 
Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided 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 the enrollee does not need intensive therapies. While the enrollee may benefit from 
physical and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and alternate 
setting such as in a skilled nursing 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day sensor kit. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee is insulin-treated 
with multiple (three or more) daily administrations of insulin or a Medicare-covered continuous subcutaneous 
insulin infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 
Day sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on September 26, 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 the enrollee's rehabilitative needs warrant an IRF 
level of care. The Plan denied your request. The Plan says the requested IRF services do not meet the 
requirements for approval. 
 
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 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 need physical 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 the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 28, 2022, to 
May 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided 
documentation to support payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 28, 2022, to May 
31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-the-bed table (E0274). 
 
You asked the Plan to pre-approve an over-the-bed table. You say that you want this item. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
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 over-the-bed table (E0274).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. This claim 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 71045 billed for date of service May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic cast, unspecified removable prosthodontic 
procedure, and a case presentation, detailed and extensive treatment planning (D0470, D9450, D5899) 
provided on August 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
diagnostic cast, unspecified removable prosthodontic procedure, and a case presentation, detailed and extensive 
treatment planning (D0470, D9450, D5899) provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6196 and A6219 provided on September 
1, 2022. 
 
You asked the Plan to pay for procedure codes A6196 and A6219. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that codes A6196 and A6219 have a status code of "P" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is 
bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the 
Plan does not have to pay for procedure codes A6196 and A6219 provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed rails (E1399). 
 
You asked the Plan to pre-approve bed rails.. You say that the member needs this item. The Plan denied your 
request. The Plan says the member does not have a hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that side rails (E0305, E0310) or safety enclosures 
(E0316) are covered when they are required by the beneficiary's condition and they are an integral part of, or an 
accessory to, a covered hospital bed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bed rails. have not been met. Specifically, the member does not have a covered 
hosiptal bed. Therefore, we decided that the Plan does not have to pre-approve bed rails (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) (95720) provided on June 
14, 2022. 
 
You asked the Plan to pay for the EEG. The Plan denied your request. The Plan says charges for or in 
connection with services or supplies that are determined by the Plan to be considered experimental or 
investigational are excluded from coverage. 
 
The Plan follows Medicare rules. Medicare rules say that an electroencephalogram (EEG) is indicated for 
coverage when the patient is experiencing episodic events where epilepsy is suspected but the history, 
examination, and routine EEG do not resolve the diagnostic uncertainties. 
 
 
  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 pay for the EEG. Our reviewer says that the 
documentation does not show that the enrollee meets the coverage criteria. Our physician reviewer found the 
enrollee has residual right homonymous hemianopsia following intracranial hemorrhage (ICH) and 
spontaneous right occipital ICH with sudden headache, nausea, vomiting, and loss of vision. An EEG (95720) 
was provided to the enrollee on June 14, 2022. Our reviewer found that this enrollee has a known cause for 
their symptoms (ICH) without signs or symptoms suggestive of seizures which is required to justify EEG. Our 
physician reviewer also found that there was no clear indication or clinical circumstance that would warrant 
this test, as it would not lead to change in treatment or outcome. 
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for the electroencephalogram (EEG) (95720) provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery services provided on August 29, 
2022. 
 
You asked the Plan to waive the copayment for surgery services. You say that you disagree with the 
copayment. 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 $360 
copayment for outpatient hospital services/surgery services.  
 
You have been asked to pay a $360 copayment for surgery services. However, you are only being asked to pay 
$292.12 which is less than the required amount. This item/service falls within the outpatient hospital 
services/surgery 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 copayment for surgery 
services provided on August 29, 2022.