Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the requested hyperbaric oxygen 
therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for hyperbaric oxygen therapy. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the enrollee does not meet criteria for hyperbaric oxygen therapy. Our physician reviewer 
found the review has determined that under Medicare guidelines, the request is not medically necessary 
because the records show that the enrollee does not have a condition for which Medicare covers hyperbaric 
oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says you do not meet all the requirements for an 
LTACH admission. 
 
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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis 
and condition, 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has tried home health services and 
skilled nursing facility (SNF) care, and both have resulted in hospital readmission. The Plan denied your 
request. The Plan says an IRF admission 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the bifocal lens, the polycarbonate lens, 
and the ultraviolet lens provided on November 8, 2022. 
 
You asked the Plan to pay for the deluxe frames, the bifocal lens, the polycarbonate lens, and the ultraviolet 
lens. You say that you went to a network provider. You say you cannot afford the price of the eyeglasses. 
 The Plan denied your request. The Plan says the claim processed correctly. 
 
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 a $200 benefit. 
 
We looked at the file and the Plan's rules. Specifically, the Plan discounts $200 off the retail price. Based on 
this information, we decided that the Plan's rules for coverage of the deluxe frames, the bifocal lens, the 
polycarbonate lens, and the ultraviolet lens have not been met. Therefore, we decided that the Plan does not 
have to pay for the deluxe frames, the bifocal lens, the polycarbonate lens, and the ultraviolet lens provided on 
November 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like 1 to 2 more weeks of therapies. You 
also say that you feel stronger every time you are with them, and feel a few more weeks will get you back to 
normal. The Plan denied your request. The Plan says the extension of the SNF stay 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support services provided on November 1, 
2021. 
 
You asked the Plan to pay for the advanced life support services. You say that the medical records provided 
support the need for the ambulance transport. The Plan denied your request. The Plan says the ambulance 
transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the advanced life support services. Our 
reviewer says that the transport via ambulance was not medically necessary. Our physician reviewer found an 
intravenous (IV) was established, but IV medications were not administered, and ALS interventions were not 
provided.  As such the billing of ALS2 is not supported. 
 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 advanced life support services have not been met. Therefore, we decided 
that the Plan does not have to pay for advanced life support services provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99239 billed for dates of service 
July 25, 2022, to July 26, 2022. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the diagnosis code is not acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99233 and 99239 was billed with primary diagnosis code R65.20, severe sepsis without 
septic shock. There is a code first and use additional code note at the manifestation code, R65.2. This means 
that these codes are never permitted to be used as first listed or principal diagnosis codes. 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 procedure codes 99233 and 99239 billed for dates of service 
July 25, 2022, to July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the enrollee can very quickly 
regain their arm function for practical ADL/IADL completion, improving their independence at home, and 
therefore avoid overuse injuries to the unaffected arm as well as other complications inherent in sedentary 
living. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered by Medicare. 
 
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 a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition of upper extremity partial paralysis from a traumatic brain injury. 
The requested device is not in widespread use for this enrollee's condition based on scientific evidence. There 
is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro powered arm brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says you do not meet the criteria for continued 
SNF services. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gurney van transportation provided on December 13, 
2022. 
 
You asked the Plan to pay for the gurney van transportation. You say that you would like to be reimbursed $70 
for the cost of the ambulance, which is the difference between the cost of the ambulance ($120) and your co-
pay ($50). The Plan denied your request. The Plan says gurney van transportation is not a covered benefit 
under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for gurney van transport 
services.  
 The services you have asked the Plan to pay for are gurney van transport services. Therefore, we decided that 
the Plan does not have to pay for the gurney van transportation provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coatings (V2750), ultraviolet lenses 
(V2755), and polycarbonate or equal lenses (V2784) provided on December 27, 2022. 
 
You asked the Plan to pay for the anti-reflective coatings, ultraviolet lenses, and polycarbonate or equal lenses. 
You say that when you recently ordered your new glasses, you asked what your insurance covers and were 
advised of the costs and what your insurance covered. You also say if this information was not right, they 
should not have indicated to you that your insurance would pay for part of your glasses. The Plan denied your 
request. The Plan says lens enhancements are non-covered benefits. The Plan also says that it was confirmed 
with the optical shop that you paid in full, and do not owe any additional amount for these lenses. 
 
 
 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. 
 
We looked at the file and the Plan's rules. Specifically, these lens options you received are lens enhancements. 
Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coatings, 
ultraviolet lenses, and polycarbonate or equal lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the anti-reflective coatings (V2750), ultraviolet lenses (V2755), and polycarbonate or 
equal lenses (V2784) provided on December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device (L7900). 
 
You asked the Plan to pre-approve a vacuum erection device. 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 say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a vacuum erection device (L7900).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs an LTACH level of 
care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 home health services are not supported in the medical record. Specifically, clinical notes were 
not provided for all the billed dates of service. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 test (86328) provided on September 3, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that you feel this service should be covered because 
when you spoke with the Plan on October 14, 2022, and November 13, 2022, you were not advised that this 
service would not be covered. The Plan denied your request. The Plan says that COVID-19 testing is only 
covered for diagnosing illness for COVID-19. The Plan says when they spoke with you on October 14, 2022, 
they advised that medically necessary COVID-19 testing would be covered in full. The Plan also says that 
when you contacted the Plan on November 13, 2022, you did not ask a specific question about this was for 
travel. 
 
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. The records do not support that this COVID-19 test was provided for traveling 
purposes. You did not state in your appeal why you received this service. The phone logs between you and the 
Plan also do not show that you requested information for COVID-19 testing specifically for traveling purposes. 
This means that the Plan has not provided a valid reason for denying payment of the COVID-19 test. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the COVID-19 
test (86328) provided on September 3, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the service 
should be covered because the ambulance crew refused to transport you. You also say that you ended up taking 
a different ambulance to the hospital later on. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 5, 2022.