Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 medical problems are stable. The enrollee does not require services at the LTACH 
that are not available at the acute care hospital where he is currently receiving care. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the 
enrollee. 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service August 27, 
2021. 
 You asked the Plan to pay for procedure code 71045. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 32555, and you 
did not bill with an appropriate modifier that would allow for separate payment. 
 
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 71045 
is a column II code to column I code 32555. 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 procedure code 71045 billed for date of service August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on November 
22, 2021. 
 
You asked the Plan to waive the copayment for eye exam. You say that you went for your annual routine eye 
exam and think the provider overstated the services just to collect an extra charge. The Plan denied your 
request. The Plan says the copayment amount you are being charged 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 $40 
copayment for diagnostic eye exam. The record shows that this visit addressed a non-routine diagnosis, so a 
diagnostic eye exam with copayment applies to this claim. 
 You have been asked to pay $40 copayment for eye exam. Eye exam 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 copayment for an eye examination provided on November 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) 
provided on December 21, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you went in once and had 
a $500 limit and you paid $375. You also say that you should have had $125 towards the payment and you do 
not understand why it was not paid. The Plan denied your request. The Plan says your maximum benefit has 
been met for the 2021 benefit year. 
 
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 Plan offers a $500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the December 21, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two 
additional intraoral periapical x-rays (D0230 x2) provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of an intrauterine device (IUD) provided on 
October 28, 2021. 
 
You asked the Plan to pay for IUD. You say that this service was medically necessary. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because this is not covered by Medicare 
for the diagnosis indicated. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
insertion of an intrauterine device (IUD) provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (inserts) provided on November 12, 2021. 
 
You asked the Plan to pre-approve foot orthotics or inserts. You say that foot inserts were medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from severe diabetic foot disease, and you do not wear a leg brace. 
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (inserts) 
provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for procedure code 99072. You say that the Plan underpaid this claim. The Plan 
denied your request. The Plan says payment for this code is always bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that for services billed under the Medicare Physician 
Fee Schedule that have a status indicator of B, payment is always bundled into payment for other services.  No 
separate payment is ever made.  Procedure code 99072 has a status indicator of B on the Medicare Physician 
Fee Schedule Database. Therefore, we decided that the Plan does not have to pay for procedure code 99072 
billed for date of service October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation 
(A0427) and ground mileage (A0425) provided on April 22, 2021. 
 
You asked the Plan to waive the copayment for the emergency ambulance transportation and ground mileage. 
You say that you were experiencing extreme dizziness from COVID-19 and could not drive yourself to the 
hospital. The Plan denied your request. The Plan says the copayment amount that you are being charged 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 a $200 
copay each way for Ambulance services.  
 
You have been asked to pay a $200 copay each way for the emergency ambulance transportation and ground 
mileage. The emergency ambulance transportation and ground mileage falls within the Ambulance 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 waive the copayment for the emergency ambulance 
transportation (A0427) and ground mileage (A0425) provided on April 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a psychotherapy visit provided on September 8, 2021. 
 
You asked the Plan to pay for psychotherapy visit. You say that this is a billable and payable code per 
Medicare guidelines. The Plan denied your request. The Plan says that the denial of payment for this service is 
correct, because the adjustment amount cannot equal the total service or claim charge amount and must not 
duplicate provider adjustment amounts. 
 
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 did not provide any applicable rule or evidence to support their denial 
of payment on the basis that an adjustment amount cannot equal the total service or claim charge amount or 
duplicate provider adjustment amounts that have resulted from prior adjudication. This service is covered by 
Medicare and the Plan has not disputed the coverage or medical necessity of the service. Therefore, the Plan 
has not shown that its decision to deny payment for this service is correct or justified according to Medicare 
rules. Therefore, we decided that the Plan has to pay for a psychotherapy visit provided on September 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You do not have a diagnosis for which Medicare covers a home ventilator: neuromuscular disease, 
thoracic restrictive disease, or chronic obstructive pulmonary disease (COPD) with chronic carbon dioxide 
(CO2) retention. There is no ABG done as an outpatient when stable showing increased partial pressure of 
carbon dioxide (PaCO2). Bilevel positive airway pressure (Bipap) has not been tried and failed at home. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice related services provided to the enrollee on 
September 11, 2020. 
 
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 patient was enrolled in a federal hospice program during the time services were rendered 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice related services provided to the enrollee on 
September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract saying that these lab 
services are included in the payment to the dialysis facility. The Plan denied your request. The Plan says 
payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for routine eyewear you purchased on December 3, 2021. 
 
You asked the Plan to pay more for the routine eyewear. You say that you are very disappointed that this was 
denied. The Plan denied your request. The Plan says this claim was paid up to the maximum $300 allowed for 
routine eyewear.  Any costs above the $300 limit are not covered.  
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 routine eyewear up to $300 per year. The Plan has already paid $300 towards this 
eyewear, so any costs above that amount are your responsibility. Based on this information, we decided that the 
Plan's rules for additional coverage of the routine eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay more for routine eyewear you purchased on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract saying that these lab 
services are included in the payment to the dialysis facility. The Plan denied your request. The Plan says 
payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were performed in good faith and 
should be covered. The Plan denied your request. The Plan says unauthorized non-plan care is not covered.  
The Plan says that neither your lab nor the referring provider is a contract provider with the Plan. 
 
 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. 
 
You are not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found 
no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan 
does not have to pay for lab services provided on July 27, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased on March 29, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you did not know you had to use the Plan vendor 
and you cannot afford these hearing aids. The Plan denied your request. The Plan says hearing aids purchased 
from any non-designated vendor are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plan's designated hearing aid vendor. You did not purchase these 
hearing aids from the Plan's designated vendor. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids you purchased on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxervate solution 20 mcg/Ml. 
 
You asked the Plan to pre-approve Oxervate solution. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 pre-approve Oxervate solution 20 
mcg/Ml.  
 Benefits for Oxervate solution may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns for teeth #3 and 5 (D6740) and pontic 
for tooth #4 (D6245). 
 
You asked the Plan to pre-approve retainer crowns for teeth #3 and 5 and pontic for tooth #4. You say that the 
services are necessary. The Plan denied your request. The Plan says the benefit 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. The Plan covers pontics and 
crowns once per tooth every 5 years. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of retainer crowns for teeth #3 and 5 and pontic for tooth #4 have not been met. Specifically, the 
requested services exceed the plan allowance. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns for teeth #3 and 5 (D6740) and pontic for tooth #4 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a vagus nerve stimulator (VNS). 
 
You asked the Plan to pre-approve the VNS placement. You say that there is evidence that this can be an 
effective treatment for the enrollee's condition. This should be allowed as other treatments have failed. The 
Plan denied your request. The Plan says this is not covered per the Medicare National Coverage Determination. 
 
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 VNS placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male with intractable, debilitating hiccups. He has failed multimodal 
conservative management for the hiccups. It is noted that the enrollee has a very hard time talking and eating, 
and cannot function properly at work or at home because of the constant diaphragmatic spasms. 
 
 
 The FDA approved VNS for treatment of refractory epilepsy in 1997, and for treatment-resistant depression in 
2005. The medical literature supporting VNS for the treatment of refractory hiccups is limited to several case 
reports. There is insufficient evidence to support that VNS is medically reasonable and necessary for the 
enrollee in this case. 
 
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 VNS placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a vagus nerve stimulator (VNS).