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

 
We decided that the Plan does not have to pay for contact lenses provided on June 8, 2022. 
 
You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says you used your 
benefit for contact lenses on January 19, 2021. You are not eligible for eyeglasses or contact lenses until 
January 19, 2023. 
 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 every two years. 
 
We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on   
January 19, 2021, and you are not eligible for eyeglasses or contact lenses until January 19, 2023. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for contact lenses provided on June 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injection (J0585). 
 
You asked the Plan to pre-approve Botox injection. You say that none of the drugs you have been prescribed 
work for you. The Plan denied your request. The Plan says none of the Medicare approved drug lists 
(compendia) consider the use of this drug for your illness as a medically accepted FDA approved or off label 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox injection. Our reviewer says that 
the requested use of Botox is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested use of Botox is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox injection (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 23, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment services (G2067) provided on December 
14, 2022. 
 
You asked the Plan to pay for the Opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. Medicare rules also say that only an entity enrolled 
with Medicare as an OTP can bill these codes. 
 
We looked at the file and Medicare rules. The claim was billed by a practitioner and not by a hospital, Critical 
Access Hospital (CAH), or Free-Standing Opioid Treatment Program facility. Based on this information, we 
decided that Medicare rules for coverage of the Opioid treatment services have not been met. Therefore, we 
decided that the Plan does not have to pay for Opioid treatment services (G2067) provided on December 14, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan of extremity veins including responses to compression 
and other maneuvers; unilateral or limited study (code 93971) provided on July 8, 2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins including responses to compression and other 
maneuvers; unilateral or limited study. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that this service does not meet the coverage requirements in the applicable Local 
Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
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 not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for a duplex scan of extremity 
veins including responses to compression and other maneuvers; unilateral or limited study (code 93971) 
provided on July 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 19, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the physician's services. You say that you were told by a member services 
representative that you could see an out-of-network provider. The Plan denied your request. The Plan says the 
member does not have out-of-network benefits. There is no documentation that this member was referred to 
this non-contracted provider by a contracted provider, as well as no indication of any attempt made to obtain 
prior authorization for the out-of-network services. The Plan also says the Plans call records were also 
reviewed, and it was founded the member, nor the provider, contacted the health Plan prior to services being 
rendered to confirm eligibility or benefits. 
 
 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on December 19, 2022, by an 
out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided from February 2, 2021, to  
March 30, 2021. 
 
You asked the Plan to pay for dialysis services. The Plan denied your request. The Plan says the claims were 
submitted after the filing limit. 
 
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 dialysis services was not filed until October 11, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dialysis services provided from February 2, 2021, to March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm (AAA) 
(76706) provided on December 19, 2022. 
 You asked the Plan to pay for the AAA screening study. You say that this was a wellness check on aortic 
aneurysm. The Plan denied your request. The Plan says your benefit for this type of service has been exhausted. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Though Medicare does not cover tests solely for screening purposes, an ultrasound screening for abdominal 
aortic aneurysms (AAA) is one of the exceptions to this rule. The Plan offers a benefit for this service, and is 
limited to a one-time screening ultrasound for people at risk. The record shows that you received an AAA 
screening study on November 28, 2016, and October 24, 2018, and your AAA screening benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the screening study for abdominal 
aortic aneurysm (AAA) (76706) provided on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 
billed for date of service August 4, 2021. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
this code is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377 and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377 and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377 and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 billed for date 
of service August 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you confirmed that there is a 
NOA on file. 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 March 15, 2022, to April 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve a subcutaneous cardiac rhythm monitor. You say that a loop recorder would 
help decide whether oral anticoagulation is still needed or not. The Plan denied your request. The Plan says the 
clinical information provided to us shows no history of or recent episodes of syncope. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet the criteria listed in the rules 
section for coverage of a subcutaneous cardiac rhythm monitor. 
 
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 a subcutaneous cardiac rhythm monitor. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for a subcutaneous cardiac rhythm monitor. In summary, there is insufficient documentation to 
support the medical necessity for insertion of a subcutaneous cardiac rhythm monitor in this enrollees 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 a subcutaneous cardiac rhythm monitor have been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy services provided on May 19, 2022. 
 
You asked the Plan to pay for the knee arthroscopy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
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 29882 is arthroscopy, knee, surgical; with meniscus 
repair (medial OR lateral). 
 
We find that CPT code 29882 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a surgical knee arthroscopy, with meniscus repair (medial OR lateral); therefore, 
code 29882 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the knee arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee arthroscopy services provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
documentation does not support functional impairment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 The file shows that services were requested for a scar and the asymmetric appearance of the face. We looked at 
the file, and Medicare rules. Any surgical procedure directed at improving appearance is not covered. Based on 
this information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve plastic surgery services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve spinal cord stimulator trial. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SCS trials are only covered for certain indications. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic Right Upper Quadrant Abdominal pain. The 
enrollee's current medications include Hydrocodone, Oxycodone and Belbuca. The enrollee has tried exercise, 
massage, heat, ice and physical therapy. The enrollee had a sympathetic block which did not decrease the pain. 
The enrollee has also had an Epidural steroid injection. The enrollee has psychological clearance for a SCS 
trial. There is no history of spine surgery or any other indications. The enrollee does not have an evidence-
based indication for this procedure. Therefore, the enrollee does not meet criteria for the requested 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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal cord stimulator (SCS) trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim implantation (0266T). 
 
You asked the Plan to pre-approve Barostim implantation. You say that this device is medically necessary for 
functional improvement and symptom management related to progressively worsening heart failure. The Plan 
denied your request. The Plan says the documentation indicates that the requested Barostim 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 Barostim implantation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in August 2019, the FDA approved this system for use in enrollees with 
refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This 
was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of 
life, and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary 
in this enrollees 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 Barostim implantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim implantation (0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that it is hard for the enrollee to use the lancet 
device. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
 
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 indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of an 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique; with insertion of an 
intraocular anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or 
more (66991 x 2). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
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 this service. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that per the American Academy of Ophthalmology preferred practice patterns; 
medical management is the initial treatment of choice for glaucoma. In this case, the enrollee is insisting to not 
use glaucoma eye drops. Therefore, the services are being requested for the convenience of the enrollee. There 
is no documentation provided that indicates the enrollee has tried/failed glaucoma eye drops. The Hydrus stent 
is indicated for the treatment of glaucoma for patients that are currently on glaucoma eye drops. Therefore, the 
enrollee does not meet criteria for coverage of the requested 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extracapsular cataract removal with insertion of an intraocular lens prosthesis (1 stage 
procedure), manual or mechanical technique; with insertion of an intraocular anterior segment aqueous 
drainage device, without extraocular reservoir, internal approach, one or more (66991 x 2).