Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for dialysis laboratory services provided to the enrollee on June 3, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that a corrected claim is needed with the correct information for payment. 
 
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 plan claims that multiple information items are missing for the various 
denied codes in this case. The plan has not substantiated their denial as they have not cited any Medicare 
statute as to where these denials are coming from. It cannot be verified if the plan's denial is valid. Therefore, 
we decided that the Plan has to pay for dialysis laboratory services provided to the enrollee on June 3, 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: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lenses provided on January 15, 2021. 
 
You asked the Plan to pay for the frames and lenses. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says the claim submitted by the provider to EyeMed was 
processed carrying a patient responsibility of $771.20 as the provider is out-of-network with the Plan paying 
the $90 benefit limit. 
 
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 with an out-of-network provider up to $90 per calendar year. We 
looked at the file and the Plan's rules. The file shows that the Plan paid the $90 benefit limit for the vision 
services provided on January 15, 2021. The contract clearly says you are responsible for the remaining amount. 
Therefore, we decided that the Plan does not have to pay for the frames and lenses provided on January 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational devices 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found although the documentation gives evidence that myo-electric orthosis can generally help post-stroke 
patients with upper limb paresis recover ability to perform activities of daily living (ADLs), there are no 
specific documented goals for this patient or clinical reasons of why a myo-electric orthosis would be required 
to achieve a specific ADL task for this patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro powered arm brace for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture (97811, 97810) and infrared therapy 
(97026), provided on February 2, 2022, through February 16, 2022. 
 
You asked the Plan to pay for the acupuncture and infrared therapy. You say that the services are medically 
necessary. The Plan denied your request. The Plan says infrared therapy is not a covered service and 
acupuncture is not covered without the appropriate level of supervision of a physician, PA, or NP/CNS. 
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the 
acupuncture (97811, 97810) and infrared therapy (97026), provided on February 2, 2022, through February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injection. 
 
You asked the Plan to pre-approve trigger point injection. You say that you would like the plan to reconsider 
their 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 trigger point injections 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 trigger point injection. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have several areas of pain. The documentation does not support focal 
tenderness, a palpable taut band or any response to snapping palpitation. Therefore, you do 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 trigger point injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger point injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) and fluoride varnish provided on 
December 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not realize the $500 benefit included 2 
prophylaxis visits and anything else needed. You say that you thought you had 2 visits covered separate from 
the $500 benefit. You also say that you are not sure if it was your own misunderstanding or if the benefits were 
not explained correctly. The Plan denied your request. The Plan says the $500 maximum benefit for dental 
services has 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 and the services are listed as covered, 
the $500 maximum benefit has been exhausted. The record shows that the Plan paid $330 for services received 
on January 20, 2021, $167 for services received on June 7, 2021, and $3 for services on the date of service in 
this case. $330 + $167 + $3 = $500. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) and fluoride varnish provided on December 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 11, 2021, to April 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the decision to remove codes A41.59 and R65.20 and downgrade to DRG 690 was appropriate.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found DRG 690: KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 
is the appropriate DRG for this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 11, 2021, to April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery at the in-network benefit level 
provided on March 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery. You say that you would like the OON provider to be 
covered under in-network benefits because of the unique expertise the OON provider has. The Plan denied your 
request. The Plan says the claims were processed correctly at the enrollee's OON benefit rate. Also, there was 
in-network specialist that were available that could have provided the same service. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Point-of-
Service (POS) benefits. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. We found no exception that would 
require the Plan to pay these items/services at the in-network benefit levels. Therefore, we decided that the Plan 
does not have to pay for the outpatient surgery at the in-network benefit level provided on March 8, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity electric orthotic device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request falls into the class of experimental and unproven. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found given that the medical literature examining the efficacy of the device is limited, it is possible that it may 
benefit some patients. However, it is not possible to make this recommendation for all patients and the clinical 
documentation provided does not demonstrate objective outcome measures that the requested MyoPro has or 
will improve the function of the current patient. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an upper extremity electric orthotic device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
electrode array, epidural for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not indicate that this being done as a last resort, or late resort for patients 
with intractable pain. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. There are 
several evidence based therapies available at this time. The request 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous implantation of a neurostimulator electrode array, epidural for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine provided on October 21, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment will be made by Original 
Medicare for the COVID-19 vaccine. 
 
The Plan must follow Medicare rules. Medicare rules say that for patients enrolled in a Medicare Advantage 
(MA) Plan in 2020 and 2021, submit COVID-19 vaccine administration claims to Original Medicare through 
your Medicare Administrative Contractor (MAC). 
 
We looked at the file and Medicare rules. In this case, the COVID-19 vaccine is to be processed through 
Original Medicare. Based on this information, we decided that Medicare rules for coverage of the COVID-19 
vaccine have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine 
provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 11, 2021, to April 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 064 (INTRACRANIAL HEMORRHAGE OR 
CEREBRAL INFARCTION WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found while the physician documented a diagnosis of severe malnutrition, the clinical 
documented in the records did not support this diagnosis. The review has determined that the records do not 
support the principal diagnosis code E43 - unspecified severe protein calorie malnutrition. The appropriate 
DRG is 065.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 11, 2021, to April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555) and an implantable neurostimulator, pulse 
generator (L8679). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator and an implantable 
neurostimulator. You say that the requested device is to help alleviate the enrollee's current pain and increase 
her ability to participate in day-to-day activities with reducing or alleviating the need for use of opioid 
medications. The Plan denied your request. The Plan says the requested device is not covered by Medicare or 
the enrollee's Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are listed as non-covered 
will not be covered by the Plan.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a percutaneous implantation of neurostimulator and an implantable neurostimulator have not been 
met. Specifically, the requested item is listed as a non-covered item/service. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (excludes sacral nerve) (64555) and an implantable neurostimulator, pulse generator (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP supplies provided on January 28, 
2022. 
 
You asked the Plan to waive the coinsurance for CPAP supplies. You say that you shouldn't have to pay for the 
supplies for the CPAP. You said that you think they should be included. The Plan denied your request. The 
Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance Medicare covered durable medical equipment and related supplies.  
 
 
 
 
 You have been asked to pay $130.71 which is 20% of the allowed amount for the CPAP supplies. The allowed 
amount is $653.55 (20% x $653.55 = $130.71). The $37.60 that is being disputed is part of the total 
coinsurance applied. CPAP and the supplies fall 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 coinsurance for CPAP supplies provided 
on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 3, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 a domiciliary or rest home visit provided on 
September 3, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve keratoplasty. 
 
You asked the Plan to pre-approve keratoplasty. You say that the purpose of the requested surgery is not 
refractive and is to help preserve the cornea and prevent loss of the eye. The Plan denied your request. The Plan 
says that a keratoplasty/partial corneal transplant is not approved the Medicare and/or the food and Drug 
Administration (FDA) when done only to improve the enrollee's vision. 
 
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 keratoplasty. Our reviewer says that a 
keratoplasty considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has been diagnosed with Endothelial corneal dystrophy of the right eye. On March 19, 2022, it is 
documented that the enrollee's vision was not clear. Fuchs' corneal dystrophy was noted, with edema and 
decreased vision. The requested keratoplasty is to treat specific lesions of the cornea. The requested 
keratoplasty is not cosmetic, nor is it to treat refractive defects. The requested keratoplasty is considered a 
standard of care in the treatment of early to moderate Fuchs' edothelial dystrophy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of keratoplasty have been met. Therefore, we decided that the Plan has to pre-
approve keratoplasty.  
 
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 the prescription drugs (J8499), provided on May 19, 2021. 
 
You asked the Plan to pay for prescription drugs (J8499). You say that the drugs were 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 Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the prescription drugs (J8499), 
provided on May 19, 2021.