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

We decided that the Plan does not have to pay for eyeglasses provided on July 20, 2020.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says it is important to
know which providers are part of our network because, with limited exceptions, while you are a member of our
plan you must use network providers to get your medical care and services. The only exceptions are
emergencies, urgently needed services when the network is not available (generally, when you are out of the
area), out-of-area dialysis services, and cases in which the Plan authorizes use of an out-of-network provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided through the Plan's vision provider.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have
not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 20,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aid repair provided on July 13, 2021.
You asked the Plan to reimburse you for hearing aid repair. The Plan denied your request. The Plan says
services must be received from the Plan's hearing provider.
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 plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the hearing aid services were not provided by the
Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing
aid repair have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing
aid repair provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair lift (E1399). 
 
You asked the Plan to pre-approve a wheelchair lift. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair lift (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acyclovir cream. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve acyclovir cream.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you do not have 
transportation for your dialysis treatments 3 times per week. You also say that you will try find someone to 
take you to the dialysis center. The Plan denied your request. The Plan says the routine transportation benefit 
has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Eliquis. 
 
You asked the Plan to pre-approve the Eliquis. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Eliquis.   
Benefits for the Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DyAnsys auricular stimulator (L8679, 64555). 
 
You asked the Plan to pre-approve DyAnsys auricular stimulator. You say that based on the enrollee's history 
and diagnoses, the provider is recommending the neurostimulator to decrease pain. The Plan denied your 
request. The Plan says this service is unproven and not a covered benefit as there are not enough studies to 
show the DyAnsys will help in your care 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of DyAnsys auricular stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve DyAnsys auricular stimulator (L8679, 64555).
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute care 
and does not require transfer to a Long-Term Acute Care Hospital (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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care, and all medically necessary care is being provided in the 
current acute care facility. Our doctor also found that the Plan has approved ongoing care in the current acute 
care facility, and the requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health services. You say that you need care at home for daily living. 
The Plan denied your request. The Plan says a physician has not developed and certified a plan of care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 We looked at the file, and Medicare rules. In this case, there are insufficient medical records that show a need 
for the requested services. The file shows that the Plan made multiple attempts to obtain additional information 
without success. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health 
skilled nursing 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. The Plan denied your request. The Plan says the enrollee is ready 
to transition to 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 physician reviewer found 
that the enrollee was admitted to an acute hospital with abdominal pain. Her hospital course was complicated 
by septic shock and respiratory failure. She is medically stable and does not need supervision by a 
rehabilitation physician 3 times per week. At the enrollee's current functional mobility, she does not need intensive therapies, consisting of at least 3 hours 
of therapy per day at least 5 days per week with a multidisciplinary approach. Therefore, an IRF admission is 
not medically necessary based on lack of medical complexity, and acute rehab nursing needs. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spiriva Handihaler. 
 
You asked the Plan to pre-approve the Spiriva Handihaler. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this is considered a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Spiriva Handihaler.   
Benefits for the Spiriva Handihaler 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. You 
say that the enrollee will fail if she goes to short-term rehabilitation. The Plan denied your request. The Plan 
says authorization denied because the LTACH is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility (SNF). 
 
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 record indicates that the enrollee requires ongoing acute care services, 
including operative intervention, before being able to transition to a lower level of care. The medical record 
does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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. The Plan denied your request. The Plan says the 
enrollee does not have multiple medical conditions which need complex medical management. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with peritonitis, kidney disease, 
requiring IV antibiotics. The course was complicated by a gastrointestinal bleed and stroke causing confusion. 
Recent notes describe the enrollee as no longer confused. The enrollee appears to be more stable and 
improving. He should only require short-term additional acute care services that can be safely administered at 
the current facility. He does not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not supported and will be considered not medically necessary at this time as it 
would not be clinically advantageous. 
 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 chiropractic manipulative treatments, office visits, and 
acupuncture provided from July 12, 2021, to September 13, 2021.  
You asked the Plan to pay for chiropractic services. You say that you did not receive any payment for these 
claims. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct. 
The Plan also says that the denial of payment for acupuncture service is correct, because this is not covered. 
 
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 $30 
copayment for chiropractic treatments and $60 copayment for office visits. The rules say that acupuncture is 
not covered by Medicare or the Plan when performed by a chiropractor. For some of the covered services, the 
Plan did not issue reimbursement because the allowed amount of the service was less than the copayment 
amount for the service. A summary of the payment of these claims is shown below: 
 
Date of Service 
Service 
Provided 
Allowed 
Amount 
Cost-Share 
Per Contract 
Reimbursement 
Amount 
July 12, 2021 Office Visit $82.98 $60 copayment $22.98 
July 12, 2021 
Chiropractic 
Treatment 
$27.33 $30 copayment $0 
July 12, 2021 Acupuncture $0 Not Covered $0 
September 8, 2021 Office Visit $53.87 $60 copayment $0 
September 13, 2021 Office Visit $53.87 $60 copayment $0 
Total    $22.98 
 
Therefore, the Plan reimbursed you $22.98. 
 
You have been asked to pay $30 copayment or less for chiropractic treatments and $60 copayment or less for 
office visits. Chiropractic services fall within the "Chiropractic Services" and "Physician/Practitioner Services, 
Including Doctor's Office Visits" 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. Additionally, the acupuncture service is not covered by Medicare or the Plan 
when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for chiropractic 
manipulative treatments, office visits, and acupuncture provided from July 12, 2021, to September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on July 1, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that the denial should be reconsidered
based on the attached supporting documentation. The Plan denied your request. The Plan says CPT code 93352
denied due to status indicator M for a service not billable to the MAC and all remaining lines were denied for
the edit error on another claim line.
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 93352 is use of echocardiographic contrast agent during
stress echocardiography (List separately in addition to code for primary procedure).
We find that CPT code 93352 is not supported in the medical record. Specifically, CPT code 93352 has a status
indicator of M. This means that the service is not billable to the MAC or payable under the Outpatient
Prospective Payment System. Since CPT code 93352 cannot be paid, the additional services billed cannot be
paid. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services
provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coflex device surgery (22867, 69990). 
 
You asked the Plan to pre-approve coflex device surgery. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet 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 coflex device surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the coflex device is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of coflex device surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve coflex device surgery (22867, 69990).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 is medically stable and does not need PM&R physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee's rehab needs can be met 
safely and provided at 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.