Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the appropriateness and medical necessity of a transthoracic echocardiogram (TTE), 
in the absence of any supportive clinical evidence of a cardiac abnormality or symptoms. Clinical guidelines do 
not support carrying out a TTE in this setting. In summary, there is no supportive evidence for the medical 
necessity of a TTE in this enrollees clinical management. 
 
   
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on June 4, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance service was not medically necessary. Our 
physician reviewer found the enrollee was transported to a nursing home upon hospital discharge. The record 
indicates that the enrollee was transported via stretcher. The record does not indicate that the enrollee's clinical 
condition is such that other methods of transport, such as stretcher van, are contraindicated or that the expertise, 
services and life-sustaining equipment that only a fully equipped ambulance can provide was required. 
 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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on June 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM). 
 
You asked the Plan to pre-approve the implantation of a cardiac contractility modulation system in the form of 
the Optimizer Smart device (CCM). You say that this service is medically necessary. The Plan denied your 
request. The Plan says this service is considered experimental. 
 
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 implantation of a cardiac 
contractility modulation system in the form of the Optimizer Smart device (CCM). Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this service is considered experimental. 
 
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 implantation of a cardiac contractility modulation system in the form of the Optimizer Smart device (CCM) have not been met. Therefore, we decided that the Plan does not have to pre-
approve the implantation of a cardiac contractility modulation system in the form of the Optimizer Smart 
device (CCM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional months of continued power wheelchair 
rental. 
 
You asked the Plan to pre-approve 4 additional months. You say that you have had your chair since 2021. You 
say that you are afraid they will come and take your chair. You say that you need to appeal this denial so you 
can keep your power wheelchair. The Plan denied your request. The Plan says no additional payment beyond 
13 months will be made. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for capped rental items are only made 
for 13 months, at which point the beneficiary takes over ownership of the equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 4 additional months have not been met. The record shows that your power wheelchair was delivered in February 2022. Therefore, we decided that the Plan does not have to pre-approve 4 additional 
months of continued power wheelchair rental.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair purchased on August 5, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the wheelchair is only covered when rented and you purchased the item. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. Lump-sum purchase is not permitted.  
 
In this case, the Plan has approved coverage for rental of a power wheelchair. We encourage you to contact the 
Plan to arrange for rental of a power wheelchair. However, the power wheelchair you have requested cannot be 
provided through a lump-sum purchase. Therefore, we decided that the Plan does not have to pay for the 
wheelchair purchased on August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of custom ocular prosthetic (V2623 x 2), 
enlargement of ocular prosthesis (V2625 x 2), reduction of ocular prosthesis (V2626 x 2), and polishing of 
ocular prosthesis (V2624 x 2) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the prosthetic services. You say that the network provider is not even in 
business anymore. The Plan denied your request. The Plan says there is a network provider available. 
 
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 confirmed there is a 
network provider 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 replacement of custom ocular prosthetic (V2623 x 2), enlargement of ocular prosthesis (V2625 x 2), reduction of ocular prosthesis (V2626 x 2), and polishing of ocular prosthesis (V2624 x 2) to be 
provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polycarbonate lens provided on December 9, 2022. 
 You asked the Plan to pre-approve the polycarbonate lens. You say that you were not aware that this service 
was not covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 does not cover this service. 
 
We looked at the file and the Plan's rules. the polycarbonate lens is an enhancement and not a covered benefit. 
Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lens have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the polycarbonate lens provided on 
December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that the Plan and provider told you that the 
provider was in-network. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a maxillary 
partial denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for 
LTACH The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as an acute rehabilitation facility, skilled nursing facility, nursing 
facility, outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with altered mental status and 
cold exposure with atrial fibrillation with rapid ventricular response (RVR) complicated by sepsis, 
hypertension, and dementia. The medical record showed the enrollee was responding to treatment with plans 
for a few more weeks of intravenous antibiotics. The enrollee appears to be improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you want to receive the SSBCI benefit for 
help with utilities. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible 
for SSBCI benefits. 
 
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 did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, we decided that the Plan has to pre-approve the 
SSBCI benefits.  
 
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 waive the cost-share for the Eyelea injection and its administration 
provided on October 26, 2022. 
 
You asked the Plan to waive the cost-share for the Eyelea injection and its administration. You say that you are 
disputing this coinsurance amount. 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 20% 
coinsurance for Medicare-covered Part B drugs and a $5 copayment for all other Medicare-covered vision 
services.  
 
You have been asked to pay $361.20 which is 20% of the allowed amount coinsurance for the Eyelea injection. 
The allowed amount is $1,805.99. ($1,805.99 x 20% = $361.20). You have also been asked to pay a $5 
copayment for the administration of the injection. The administration falls within the vision care 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 cost-share for the Eyelea injection and its administration 
provided on October 26, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81216, 81238, 81241, 
81242, 81249, 81279, 81298, 81317, 81321, 81334, 81339 and 81345. We decided that the Plan does not have 
to pay for the services described by procedure code(s) 81307.  
 
You asked the Plan to pay for laboratory services provided on July 29, 2022. You say that these services were 
medically necessary and are supported in the medical record. The Plan says that the number of units of 81307 
billed exceeds the maximum allowed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81216, 81238, 81241, 
81242, 81249, 81279, 81298, 81317, 81321, 81334, 81339 and 81345.  
 
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 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 the services described by procedure code(s) 81216, 81238, 81241, 81242, 
81249, 81279, 81298, 81317, 81321, 81334, 81339 and 81345.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81307. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81307 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 81307 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 81307. 
 
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 pre-approve a FreeStyle Libre 2 reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 reader. The Plan denied your request. The Plan says a 
continuous glucose monitor is not covered under Medicare if the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 reader.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery. 
 
You asked the Plan to pre-approve the outpatient surgery. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the medical necessity criteria were not met because there is a 
contradiction in the records about the symptoms the member is complaining of, and the results of the tests 
performed do not show that there is blockage severe enough to recommend the requested procedures. 
 
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 outpatient surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the details in the surgeon appeal letter are so different from the objective findings in 
the medical record that it would be important to be sure that the surgical plan is concordant with the patient 
findings. 
 
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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that the transport service to the physician's 
office was medically necessary. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.   
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the anesthesia services are covered under 
the surgeons or facilities authorization. You say that the attached medical records should be reviewed, and 
payment issued. The Plan denied your request. The Plan says procedure code 00731 has been paid. The Plan 
also says that procedure code 99100 is considered bundled and not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 20, 2022.