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

 
We decided that the Plan does not have to pay for the high-index lens (V2782), custom progressive lens 
(V2781), anti-reflective coating (V2750), and photochromatic lens (V2744), provided on December 23, 2021. 
 
You asked the Plan to pay for the lens enhancement services. You say that the items should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 with up to a $200 allowance for eyeglasses, frames, or lenses every 
year. Enhancements are NOT covered through the allowance but may be purchased by the member at an 
additional cost. 
 
We looked at the file and the Plan's rules. Enhancements are NOT covered through the allowance but may be 
purchased by the member at an additional cost. Based on this information, we decided that the Plan's rules for 
coverage of the lens enhancement services have not been met. Therefore, we decided that the Plan does not 
have to pay for the high-index lens (V2782), custom progressive lens (V2781), anti-reflective coating (V2750), 
and photochromatic lens (V2744), provided on December 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy. 
 
You asked the Plan to pre-approve diagnostic procedure. You say that the required preparation for this 
procedure is the same as a colonoscopy. You also say that having to do both preparations would be a hardship to go through at your age. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Colon Capsule Endoscopy (CCE) is medically 
necessary when certain criteria are met. 
 
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 diagnostic procedure. Our reviewer 
says that the requested diagnostic procedure is not medically necessary. Our physician reviewer found the 
record indicates that you have a history gastrointestinal bleeding from gastric and duodenal arteriovenous 
malformations treated in March 2022. The record indicates that you have not had a recent colonoscopy. The 
record does not indicate the presence of an enumerated condition for which coverage is available for the 
requested service under the coverage criteria. Therefore, the reviewer found that the elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a laryngoscopy performed on November 30, 2021. 
 
You asked the Plan to waive the copayment for the laryngoscopy. You say that this was a diagnostic service 
performed in a doctor's office. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). Specifically, the Plan has not forwarded a complete copy of the 2021 
Evidence of Coverage (EOC). Without this contract information, we are unable to verify the cost share amount 
applied to the appealed service. It is the burden of the Plan to substantiate their denial with evidence. In this 
case, the Plan's denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan 
has to waive the copayment for a laryngoscopy performed on November 30, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 25, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on March 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 11, 2021. 
 
You asked the Plan to pay for code 70450. 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the Computed tomography (CT) scan (70450) provided on 
October 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you no longer require daily skilled services and the continuation of 
SNF 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 8, 
2021. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that the medical claim was billed 
correct using the correct Place of Service code and the medical records substantiate the place of the service. 
You say that you are requesting the redetermination be considered and payment issued. The Plan denied your 
request. The Plan says Medicare rule for payment of this claim has not been met. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, items and non-physician 
services furnished to inpatients must be furnished directly by the hospital or billed through the hospital. Based 
on this information, we decided that Medicare rules for coverage of moderate sedation services (99153) have 
not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) 
provided on December 8, 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 the clinical documentation provided supports the 
need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 
not been met. The Plan says that the enrollee does not need an intensive program with a team of health care 
professionals and doctors that specialize in complex medical needs as well as rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar infection and had lumbar laminectomy and incision and drainage. The enrollee's 
medical problems are stable. 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 has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
May 23, 2021. 
 
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 there is no valid standard written order. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on May 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require complex daily nursing care that must be provided in 
a skilled nursing facility. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, it is my 
opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more 
than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs, as a practical matter, can 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (80307, G0480, G0481) rendered by 
the out-of-network (OON) provider on October 29, 2021 and December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 drug testing services (80307, G0480, G0481) rendered by the out-of-network 
(OON) provider on October 29, 2021 and December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutch substitute (code E0118) provided from October 4, 
2021, to December 4, 2021. 
 
You asked the Plan to pay for the crutch substitute. You say that the patient had a procedure done and required 
a knee scooter to be able to get around. The Plan denied your request. The Plan says this is not a covered item 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that crutch substitutes (code E0118) are not covered 
for any reason. Therefore, we decided that the Plan does not have to pay for the crutch substitute (code E0118) 
provided from October 4, 2021, to December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on November 
1, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that the claim was denied for no 
authorization, but you have authorization for 12 visits. The Plan denied your request. The Plan says CPT codes 
97140 and G0238 were reprocessed and paid. The Plan also says CPT code 97010 remains denied as bundled 
services are not eligible for separate payment.  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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have 
to pay for the hot or cold packs therapy (97010) provided on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on December 26, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76700. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 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 76700 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76700) provided on December 26, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on August 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says they should have billed with no modifier if billing for both components. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider reported services with a 
technical component (TC) and a -26 modifier. Per Medicare guidelines, when reporting both technical 
component and professional component, no modifier would be appended, unless only the TC or professional 
(PC) component was performed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for x-ray services provided to the enrollee on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear your received on January 10, 2022. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has 
been reached. 
 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 when up to $500 every 12 months. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid $383.76 toward eyewear you 
received on November 4, 2021. This means that $116.24 of the $500 maximum benefit was left. The Plan paid 
$116.24 toward the eyewear you received on January 10, 2022, which exhausted the benefit. You are 
responsible for any amount over the benefit limit. Based on this information, we decided that the Plan's rules 
for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for 
the eyewear your received on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor 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 enrollee's records indicate that they have not used a meter for 
two months, so they have not been adjusting their insulin based on their blood sugar readings. If the enrollee is 
not on insulin at least three times a day and changing the insulin dose based on their most recent blood glucose, 
Medicare does not cover CGMs or CGM supplies. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Freestyle Libre 2 Sensor.