Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression devices are not covered by 
Medicare when the place of service is an ambulatory surgical center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices were used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of an IRF admission. You say the enrollee is not walking on their own and would benefit from inpatient 
rehabilitation. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 the enrollee has continued decline consistent with their chronic disease and 
chronic functional impairment. The enrollee does not require and is unable to respond to intensive 
rehabilitation. Frequent physiatry oversight is not medically 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the power wheelchair repairs. You say that you say that you are dependent 
on your power chair, which has become increasingly unreliable. You also say that you would like a new power 
chair, or two new motors and two new batteries for your current chair. The Plan denied your request. The Plan 
says the request for repairs to your power wheelchair cannot be covered. The Plan also says per Medicare rules, 
repairs for cannot be covered if the cost of repair is more than the cost of replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that f the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
 
 
 We looked at the file and Medicare rules. Specifically, the Plan does not have to cover repairs when the sum 
total cost of repairs exceeds the cost of replacing the item. Based on this information, we decided that Medicare 
rules for coverage of the power wheelchair repairs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve power wheelchair repairs.
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 SNF admission due to medical necessity. The Plan denied your request. The Plan says the request for a SNF 
admission is not shown to be 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 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 have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, the 
enrollee does not require skilled therapy services on a daily basis. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. This enrollee 
does 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for progressive lenses, anti-reflective coating, 
and to waive the coinsurance for photochromatic lenses provided on October 21, 2022. 
 
You asked the Plan to waive the copayment for progressive lenses, anti-reflective coating, and the coinsurance 
for photochromatic lenses. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 a $65 
copayment applies to standard and premium progressive lenses and standard anti-reflective coating. There is 
also an 80% coinsurance that applies to premium progressive lenses and other coatings, and other lens options.  
 You have been asked to pay a $65 copayment for progressive lenses. You have also been asked to pay a $65 
copayment for anti-reflective coating. You have also been asked to pay $96, which is 80% of the allowed 
amount for photochromatic lenses ($120 x 80% = $96). The progressive lenses, anti-reflective coating fall 
within the standard and premium progressive lenses and standard anti-reflective coating benefit category. The 
photochromatic lenses fall within the standard and premium progressive lenses and standard anti-reflective 
coating 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 copayment for progressive lenses, anti-
reflective coating, and to waive the coinsurance for photochromatic lenses provided on October 21, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
have complex medical, and therapy needs that need an intensive therapy program. 
 
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 the enrollee's functional status and rehabilitation needs do not warrant intensive 
rehabilitation to restore or maintain function and does not require frequent physiatry oversight.  
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on July 29, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this service was 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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug testing, definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the provided records do not 
show testing for 22 or more drug classes. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing (G0483) provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the office visit provided on October 6, 2022. We decided that the Plan 
does not have to pay for the eye refraction provided on October 6, 2022. 
 
You asked the Plan to pay for the office visit and an eye refraction provided on October 6, 2022. You say that 
the services were medically necessary. The Plan says that the service is non-covered and the vision services 
plan does not cover medically related services. 
 
We decided that the Plan has to pay for the office visit provided on October 6, 2022.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered.  
The Plan follows these rules.  
 
We looked at the file and the Medicare rules. The file shows that the office visit was provided to you by a 
contract provider, who is an agent of the Plan. The file does not show that the Plan provided notice that the 
office visit would not be covered. Under Medicare rules, this means that the office visit is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the office visit provided on October 6, 2022.  
 
We also decided that the Plan does not have to pay for the eye refraction provided on October 6, 2022. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for the eye refraction provided on October 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ottoman, walker, leg support, toilet seat, commode, and 
sales tax purchased between February 8, 2022, and April 13, 2022, from providers who do not participate with 
Medicare. 
 
  You asked the Plan to pay for the ottoman, walker, leg support, toilet seat, commode, and sales tax. You say 
that you would like to appeal the durable medical equipment (DME) that was prescribed by your surgeon. The 
Plan denied your request. The Plan says these items were purchased from providers who are not Medicare 
participating providers. The Plan also says it was verified with your provider's office that you were not directed 
to purchase any of these items from any of the places you did, but you were told to verify with your insurance 
on places you could purchase from. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. Medicare rules also say that Medicare does not make separate payment for sales tax. 
 
We looked at the file and Medicare rules. Specifically, the providers you purchased these items from are not 
enrolled in Medicare, and therefore, are not eligible for payment. Based on this information, we decided that 
Medicare rules for coverage of the ottoman, walker, leg support, toilet seat, commode, and sales tax have not 
been met. Therefore, we decided that the Plan does not have to pay for the ottoman, walker, leg support, toilet 
seat, commode, and sales tax purchased between February 8, 2022, and April 13, 2022, from providers who do 
not participate with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
November 29, 2022, December 1, 2022, and December 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that you and your provider checked your coverage, 
and it showed the dental service was covered. The Plan denied your request. The Plan says the denial of 
payment for this service is correct because the periodontal scaling and root planing is not covered by the Plan. 
Also, it was verified there is no call history prior to the date of service from the enrollee to verify benefits. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing (D4341) provided on November 29, 2022, December 1, 2022, and 
December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested 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 enrollee's nursing, medical, and rehabilitation needs does 
not require an IRF stay. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle surgery and self-administered drug. 
 
You asked the Plan to pay for the ankle surgery and self-administered drug. You say that the services should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly, and self-
administered drugs are not covered. 
 
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 a $350 
copayment for outpatient hospital services.  
 
You have been asked to pay a $350 copayment for the ankle surgery and self-administered drug. This service 
falls within the outpatient hospital services 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 pay for the ankle 
surgery and self-administered drug.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for . We decided that the Plan does not have to pay for .  
 
You asked the Plan to pay for procedure code 99497 billed for date of service August 21, 2022. You say that 
you disagree with the Plans denial. The Plan says that the services are not payable as billed. 
 
We decided that the Plan has to pay for four units of code 99233 and 99291.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for four units of code 99233 and 99291.  
 
We also decided that the Plan does not have to pay for code 99497. 
 
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, we have confirmed that code 99497 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for 99497. 
 
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 skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says no documents 
reviewed of need for daily skilled therapy or nursing care, medically necessary care may be provided safely in 
a different level of care. 
 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. 
 
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 skilled nursing facility (SNF) care.