Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee braces (L1851 and L2397) provided on October 27, 
2022. 
 
You asked the Plan to pay for the knee braces. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the problem list in the medical record does not list knee pain or arthritis as 
one of the members problems. There was no specific physical examination of the knee. There is an order for a 
knee brace, but there is no commensurate note in the medical record on or around that date as to why the brace 
was being ordered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication of the knee brace or need of in the medical records. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the knee braces (L1851 and L2397) provided on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
admission to an IRF. You say that you need that level of care. The Plan denied your request. The Plan says 
your request for admission to an IRF does not meet medical necessity 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical shoe (L3260) provided on September 14, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the item was medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for the surgical 
shoe (L3260) provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee braces (L1851 and L2397) provided on October 27, 
2022. 
 
You asked the Plan to pay for the knee braces. You say that the items were medically necessary. The Plan 
denied your request. The Plan says there is no mention in the records of any knee pain or instability, or of the 
need for knee bracing. The problem list in the medical record does not list knee pain or arthritis as one of the 
member's problems and there was no specific physical examination of the knee. There is an order for a knee 
brace, but there is no commensurate note in the medical record on or around that date as to why the brace was 
being ordered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no commensurate note in the medical record on or around that date as to why the brace 
was being ordered. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee braces 
(L1851 and L2397) provided on October 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient prospective, long-term clinical data available to 
determine whether proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to 
external beam radiation therapy, intensity-modulated radiation therapy, or brachytherapy with regards to safety 
and efficacy. The records show that the enrollee is participating in "REG001-9 research study but this is 
documented to be an evaluation tracking project, an observational registry and not an interventional, 
prospective clinical trial. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 17, 
2022 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this bill. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 7, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 17, 
2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
September 11, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that this was not a 
decision you were able to make. And you were unaware there would be a 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance 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 an in-
network ambulance ride provided on September 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 ILR. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an implantable cardiac monitor (ICM). In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ICM in this enrollee's clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on July 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided for use during surgery on July 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided from December 
30, 2021, to December 31, 2021. You asked the Plan to pay for the billed services. You say that the claim was billed correctly. The Plan denied 
your request. The Plan says the dates do not match the number of days billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 days of SNF care are not supported. The dates billed on the claim only support 1 units of 
revenue code 0022. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility services provided from December 30, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on September 30, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that this is helpful for this patient, please reconsider. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lenses provided on October 17, 2022. 
 
You asked the Plan to pay for the frames and lenses. You say that you were not advised to wait a calendar year 
instead of a fiscal year to get new glasses. The Plan denied your request. The Plan says the benefit limit has 
been exceeded. 
 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 lenses and one pair of eyeglass frames every year. 
 
We looked at the file and the Plan's rules. Specifically, the benefit was exhausted on November 30, 2021. 
Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been 
met. Therefore, we decided that the Plan does not have to pay for the frames and lenses provided on October 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750), tetanus, diphtheria, and 
pertussis (Tdap) vaccine (90715), and administration (90471, 90472) provided on September 23, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that your doctor suggested you get the shingles and 
Tdap vaccines. You say that you went to a clinic and got them. You say that you were not aware you needed to 
get the vaccines at a pharmacy until the claim denied. You also say that paying more than the copayment 
amount would be a financial hardship for you. The Plan denied your request. The Plan says the preventive 
vaccine services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750), tetanus, 
diphtheria, and pertussis (Tdap) vaccine (90715), and administration (90471, 90472) provided on September 
23, 2022.  
 Benefits for the vaccine services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says there is not enough evidence showing this 
would improve the enrollee's outcome. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc 30MG/2ML (J7324). 
 
You asked the Plan to pre-approve the medication. You say that you are requesting Orthovisc, a different 
viscosupplementation, due to the poor response to Supartz. The Plan denied your request. The Plan says the 
Medicare rules have not been 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 the medication. Our physician reviewer 
found the record indicates that the enrollee has osteoarthritis of the knees and has received 
viscosupplementation therapy to both knees within the past three months without clinical benefit. The elements 
of the coverage criteria are not satisfied. The requested service is not 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-
approve Orthovisc 30MG/2ML (J7324).
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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has limited capacity for rehabilitation as her response to therapy in the 
skilled nursing facility (SNF) has shown and as her prior inability to safely use an assistive device. Intensive 
rehabilitation for hip fracture does not improve outcome over that of SNF. The enrollee does not require 
intensive rehabilitation services and does not require frequent physiatry oversight. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation provided on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the fact that an emergency tooth ache visit was 
counted as an oral examination does not make sense. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for this item. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that you have exhausted the allowable benefit 
for the requested item as you previously received an upper partial denture on June 3, 2022. However, although 
the Plan has referenced the benefit for partial dentures as one item every 60 months as indicated in the 2023 
Medicare reference guide; this information has not been provided in the Plans 2023 Evidence of Coverage 
(EOC) contract booklet. The benefit has been written for partial dentures with no limitations indicated. The 
Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the 
Plan has to pre-approve an upper partial denture (D5213).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurosurgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee requires a tertiary specialist. The 
Plan denied your request. The Plan says in-network providers are available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurosurgery services to be provided by an out-of-network (OON) provider.