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

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2784) provided on January 
20, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you do not understand why the Plan is not paying 
for these eyeglasses. The Plan denied your request. The Plan says these glasses are covered, and the Plan has 
paid the full benefit allowance toward these services. You are responsible for the charges that exceed this 
allowance. 
 
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 up to $215 per calendar year. Any amount billed by the provider 
above this allowance is your responsibility. 
 
We looked at the file and the Plan's rules. The documentation shows that the provider billed a total of $455 for 
the eyeglasses purchased on January 20, 2022. The Plan paid $215, and you are being asked to pay the 
remaining $240 ($455 - $215 = $240). Based on this information, we decided that the Plan has paid the correct 
amount for these services as indicated in the contract. Therefore, we decided that the Plan does not have to pay 
any additional amount for the eyeglasses (V2020, V2203, V2784) provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on November 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says the code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. We find that CPT code 85060 is not payable when furnished to a hospital 
outpatient. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services 
provided on November 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the future coinsurance for a hospital bed. 
 
You asked the Plan to waive the future coinsurance for a hospital bed. You say that you are paying too much, 
and this should be covered with no copayment.  The Plan denied your request. The Plan says you have been 
asked to pay the correct cost sharing amount. 
 
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 10% 
coinsurance for durable medical equipment. 
 
 
 
 
 
 The enrollee has been asked to pay 10% coinsurance for a hospital bed. A hospital bed falls within the Durable 
Medical Equipment (DME) and Related Supplies 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 
future coinsurance for a hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve A specialist office visit. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 items/services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided 
that the Plan does not have to pre-approve A specialist office visit to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of multi-component, inflatable penile prosthesis, 
including placement of pump, cylinders, and reservoir (CPT code 54405). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet generally accepted medical guidelines for clinical 
appropriateness of this surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does meet generally accepted medical guidelines for clinical appropriateness of this 
surgery. The enrollee has severe erectile dysfunction caused by his prostate cancer treatment (IMRT + Lupron) 
and has failed non-surgical treatments. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, 
and reservoir (CPT code 54405).  
 
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 facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the medical records do not show 
enrollee has pain localized to low back. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injection services are subject to the criteria 
listed 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 facet joint injection services. Our reviewer says that the requested injection services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 45-year-old woman with chronic low back pain which radiates to her 
legs. In this case, the patient has radicular symptoms and documented herniated disc with an extruded 
fragment. This does not meet the relevant Medicare criteria. The request is deemed 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 facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on 
December 9, 2021. 
 
You asked the Plan to pay for the eye exam. You say that the patient was treated for cataracts, macular drusen 
and glaucoma. You say that the service was medically necessary and the claim should be reprocessed 
accordingly. The Plan denied your request. The Plan says out-of-network services were not authorized. 
 
  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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam provided by an out-of-network 
provider on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser cataract surgery rendered on October 26, 2021. 
 
You asked the Plan to pay for these services. You say that you were told the services would be covered. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that beneficiaries must pay additional charges for non-
covered Medicare cataract procedures. 
 
We looked at the file and Medicare rules. The file shows that you received laser cataract surgery. The laser 
portion of the surgery is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for 
the laser cataract surgery rendered on October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Retacrit or Procrit 
(epoetin alfa). 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
contain documentation of trial and failure of Retacrit or Procrit (epoetin alfa). The reviewer found that the 
documentation does not support that Retacrit or Procrit (epoetin alfa) would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step 
therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set and unspecified 
infection control supplies used during anesthesia care on September 23, 2021, billed with codes S1015 and 
S8301, respectively. 
 
You asked the Plan to pay for the medical supplies as billed. You say that since you provide mobile anesthesia 
services for in-office procedures, you must bring your own equipment which should be paid by the Plan. The 
Plan denied your request. The Plan says these two codes are not valid for Medicare billing. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This 
means that these codes are not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of the medical supplies as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the intravenous (IV) tubing extension set and unspecified infection control 
supplies used during anesthesia care on September 23, 2021, billed with codes S1015 and S8301, respectively.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 20, 2021. 
You asked the Plan to pay for the services provided. You say that drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the code cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. Providers performing validity testing on urine specimens used for drug 
testing shall not separately bill the validity testing. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcatheter Aortic Valve Replacement (TAVR). 
 
You asked the Plan to pre-approve TAVR. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this procedure 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 TAVR. Our reviewer says that the 
documentation does not support that CPT 33368 (Transcatheter Aortic Valve Replacement (TAVR/TAVI) with 
prosthetic valve) is medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found the clinical information in the case file does not support that the enrollee has significant aortic valve 
disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Transcatheter Aortic Valve Replacement (TAVR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the tests should not be separately 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture treatment provided on December 13, 2021. 
 
You asked the Plan to pay for the acupuncture treatment. You say that the Plan has paid in full for previous 
acupuncture treatment. The Plan denied your request. The Plan says that the claim exceeded the members 
Wellness allowance. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
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. 
 
We looked at the file, the Plans rules and Medicare rules. The file shows that the provider billed the claim with 
diagnosis code M54.50, which is low back pain. 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 did not provide us with medical records to substantiate that the acupuncture treatment 
meets the Medicare guidelines. Additionally, the Plan has not provided us with documentation to support why 
the acupuncture treatment has exceeded coverage under the Wellness Allowance. Therefore, we decided that 
the Plan has to pay for the acupuncture treatment provided on December 13, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal scaling and root planing (D4341) provided on February 
16, 2021. 
 
You asked the Plan to pay for the periodontal root scaling and root planing. You say that you would like 
reconsideration because you paid for these services up front and believe the provider has been paid twice. The 
Plan denied your request. The Plan says that you have reached your annual limit for dental services. 
 
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 forwarded an Evidence of Coverage. Without this 
contract we are unable to verify what dental services are covered, the annual limit or if you met coverage 
criteria. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for the periodontal scaling and root planing (D4341) provided on February 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that medical records do not support these 
services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you were not showing any dangerousness to 
self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and 
cooperative with treatment. It does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or 
homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that your condition 
does not meet criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital 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. You say that IRF care would allow you to have the best outcome 
and get back to your prior level of functioning as quickly as possible. The Plan denied your request. The Plan 
says criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and nursing 
needs can be provided at 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 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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.