Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $80 more for the glasses.  
 
You asked the Plan to pay more for the glasses. You say that you paid $950 for the eyeglasses, and exceeded 
the benefit amount by $100 which you assume the responsibility for. The Plan says that you have exceeded the 
limits set in the subscriber agreement. 
 
  We decided that the Plan has to pay $80 more for the glasses.  
 
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 up to $850 per year to be used toward the purchase of eyeglasses. This benefit would 
be used over the course of the benefit year, not paid at once unless the 80% the Plan is responsible for exceeded 
$850. You are responsible for 20% coinsurance and the Plan is responsible for 80% based on the approved 
amount of out-of-network vision services.  
 
The Plan says that your $850 benefit was exhausted with this claim but only paid $680. The Plan charged you 
20% coinsurance based off the $850 benefit. However, the documentation supports the approved amount for 
the services was $950. The Plans 80% payment would be based on the approved amount, not the benefit 
amount (80% x $950 = $760). Based on this information, we decided that the Plan's rules for additional 
coverage of the glasses have been met. The Plan needs to reimburse a total of $760 for the glasses. Therefore, 
we decided that the Plan has to pay $80 more for the glasses.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing provided on 
November 18, 2021. 
 
You asked the Plan to pay for the HPV testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are only covered once every five years. 
 
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. 
 
While HPV testing is covered once every five years, the file shows that the enrollee last received HPV testing 
on November 16, 2020. Five years had not passed since the enrollee last received this testing. This means that 
the HPV testing rendered was requested solely for screening purposes. Medicare does not cover this test solely 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the Human Papillomavirus 
(HPV) testing provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the new eyeglass frames you purchased on 
February 3, 2022, from an out-of-network (OON) provider. 
 You asked the Plan to reimburse you for the new eyeglass frames. You say that you should be reimbursed up to 
the Plan's benefit for eye wear. The Plan denied your request. The Plan says payment cannot be made for 
services purchased from a routine vision provider other than the Plan's contracted routine vision vendor. 
 
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 they are purchased from a certified vision vendor with the Plan. 
 
We looked at the file and the Plan's rules. In this case, these services were purchased from an OON provider, 
not a certified vision vendor with the Plan. Based on this information, we decided that the Plan's rules for 
coverage of the new eyeglass frames have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the new eyeglass frames you purchased on February 3, 2022, from an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on 
March 23. 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the claim should be paid. The Plan 
denied your request. The Plan says there is no mention of the brace in these records. 
 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 lumbar-sacral orthosis. Our physician 
reviewer found the case file does not include documentation that a spinal orthosis would reduce pain by 
restricting mobility of the trunk or facilitate healing following an injury to the spine or related soft tissues or 
facilitate healing following a surgical procedure on the spine or related soft tissue or would otherwise support 
weak spinal muscles and/or a deformed spine. 
 
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on March 23. 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elevating leg rests coded K0195 provided on December 
5, 2021. 
 
You asked the Plan to pay for the elevating leg rests. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the items are not payable as billed. 
 
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 K0195 is elevating leg rests, pair (for use with capped 
rental wheelchair base). 
 
 
 We find that CPT code K0195 is not supported in the medical record. Specifically, this code was billed with 
modifier NU (new equipment). This item was provided with a capped rental item. This means this modifier on 
this item is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pay for the 
elevating leg rests coded K0195 provided on December 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99204, 99214) provided on 
February 23, 2022 to March 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you were not told that the doctor was not in 
network and only found out when you called the Plan to switch your primary care physician to this provider. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before 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 the outpatient office visits (99204, 99214) 
provided on February 23, 2022 to March 14, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm 
(73221). 
 
You asked the Plan to pre-approve an MRI of the arm. You say that the requested MRI is medically necessary. 
The Plan denied your request. The Plan says the requested MRI does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the arm. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a painful shoulder 
with positive Hawkins test. No plain films are reported to have been performed and conservative 
nonpharmacologic therapy has not been attempted. The requested service is not medically necessary and 
reasonable for the diagnosis and treatment of the enrollee's clinical condition at this tie. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the arm have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) of the arm (73221).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says that the enrollee does not need skilled therapy services 5 days a 
week. The Plan says that the enrollee does not need daily skilled nursing care. The Plan says that the enrollee 
can receive the care needed in another setting. 
 
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 
criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs, though monitoring of her blood pressure, dizziness and surgical wounds is reasonable.  
The enrollee does have documented skilled therapy needs.  While the enrollee is walking, she is not doing so 
consistently or safely.  Ongoing training and supervision are reasonable to establish a maintenance program 
and/or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are appealing the denial of SNF. The 
Plan denied your request. The Plan says the documentation fails to indicate the enrollee has any daily skilled 
nursing needs. 
 
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 continued SNF care. Our reviewer says 
that the enrollee no longer qualifies for SNF coverage. Our physician reviewer found the enrollee does not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 continued SNF care. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found you have a diagnosis of Chronic obstructive pulmonary disease (COPD), although 
prior pulmonary function tests show restrictive lung disease, not obstructive. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. You had hypercarbia during a recent admission for heart failure. 
This improved on bi-level positive airway pressure (BiPAP) and improved further when place back on his home continuous positive airway pressure (CPAP). The discharge plan to continue home CPAP with close 
follow-up by pulmonary is reasonable. If there is persistent hypercarbia as an outpatient with CPAP 
compliance, then you may benefit from BiPAP. But Medicare does not cover a home ventilator when used as 
BiPAP. Therefore, you do not meet criteria for the requested device. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 1, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says a claim for code 97110 billed by this 
provider was already paid on October 8, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the physical therapy services were 
already paid on another claim. Therefore, we decided that the Plan does not have to pay for the physical 
therapy services provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550 and 84100) provided on January 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Laboratory testing 
related to treatment of end-stage renal disease is bundled into dialysis services and is not separately 
reimbursable. The documentation submitted showed that the laboratory tests reported were related to treatment 
of ESRD by end-stage renal disease was indicated as a reason for the laboratory tests, dialysis occurred on the 
same date as the tests, and a separate professional visit unrelated to ESRD was not indicated in the medical 
record. Therefore, the laboratory tests are included in the dialysis services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550 and 84100) 
provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy services (CPT code 10140-AS, 49320-AS) 
provided on November 18, 2021, by a registered nurse. 
 
You asked the Plan to pay for the laparoscopy services. You say that due to network insufficiency, the out-of-
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in-network primary physician and in-network facility. The Plan denied your 
request. The Plan says this provider is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laparoscopy services have not been met. The CPT codes exhibit 
modifier AS indicating "Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant 
at surgery". According to the Medicare enrollment for non-physician practitioners- they must enroll with 
Medicare in order to receive Medicare payments. Only qualified/certified Advanced Practice Registered Nurses 
are eligible per advanced practice registered nurse manual. According to the CMS manual modifier AS, 
modifier 80-82 must also be billed as well. Based on the provider specialty indicated on NPPES, Registered 
Nurse Registered Nurse First Assistant, this provider is not eligible for reimbursement. Therefore, we decided 
that the Plan does not have to pay for the laparoscopy services (CPT code 10140-AS, 49320-AS) provided on 
November 18, 2021, by a registered nurse.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lupron Depot Kit. 
 
You asked the Plan to pre-approve a Lupron Depot Kit. You say that the requested drug is medically necessary 
or cancer will spread to other organs. The Plan denied your request. The Plan says the requested drug is a non-
preferred product. The Plan says that the enrollee does not have any stated contraindications to the preferred 
products. 
 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 a Lupron Depot Kit. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug 
Eligard before they will approve the requested drug. The enrollee has not tried and failed this required drug. 
There is no evidence that the Plan's required drug would likely be less effective and/or likely have adverse 
effects for the enrollee, as it is just a different brand of leuprolide. 
 
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 Lupron Depot Kit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Lupron Depot Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 16, 
2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (dental code D2750) for tooth 
number 29. 
 
You asked the Plan to pre-approve porcelain crown. You say that this is the only type of crown that your 
dentist uses. The Plan denied your request. The Plan says the requested dental service is not covered by the 
Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain crown (dental code D2750) for tooth number 29.