Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal this benefit because 
you have chronic conditions. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service January 29, 
2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a correct 
primary diagnosis code should be billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99233 was billed with primary diagnosis code J12.82. This diagnosis code has a code 
first notation, which means it is not permitted to be used as a primary diagnosis code. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service January 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens and the miscellaneous vision item or 
service provided on November 17, 2022. 
 
You asked the Plan to pay for the polycarbonate lens and the miscellaneous vision item. You say that you 
owned the frames from previous glasses and were told the lenses were not covered. You say you paid the entire 
amount for the glasses and should not have paid anything. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 one pair of standard lenses and frames every year. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered upgrades and are not 
covered benefits. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate 
lens and the miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to 
pay for the polycarbonate lens and the miscellaneous vision item or service provided on November 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the regadenoson injection (J2785) 
provided on November 10, 2022. 
 
You asked the Plan to waive the coinsurance for the regadenoson injection. You say that you feel that you 
should not have a copay because the doctor had you do a stress test. You also say that you only agreed because 
it was necessary for your health, you cannot afford this copay, and feel the Plan should cover this. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan also says you did not 
contact customer service prior to receiving this service to verify your plan benefits. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 You have been asked to pay a 20% coinsurance for the regadenoson injection. This item/service falls within the 
Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the regadenoson injection (J2785) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
December 22, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that the eye facility did say that 
they were part of the Plan. The Plan denied your request. The Plan says this service is not covered by your 
health plan or Medicare. 
 
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 this service when it is provided during a routine eye exam. 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye 
examination on this date of service, and refractions are only covered during routine eye exams. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on December 22, 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. You say that the services are medically necessary for the enrollee 
to receive continued medical and pain management with physical, occupational and respiratory therapy. The 
Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: 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. You say that the services are medically necessary for you to 
receive the physical therapy needed. The Plan denied your request. The Plan says the services you require can 
safely be received in a different setting such as at home with home health, in residential care, or home with 
close follow up with their doctor. 
 
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 based on the limited documentation received, you do not qualify for SNF coverage. 
You do not have documented skilled nursing or therapy needs.  Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a claviculectomy procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has considerable issues 
with the right shoulder. The Plan denied your request. The Plan says the request is not the standard of care. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for primary osteoarthritis of the right shoulder. A partial 
claviculectomy due to a recurrence of the mass in the acromioclavicular (AC) joint was requested. However, 
the provided right shoulder magnetic resonance imaging (MRI) from November 2022, demonstrated additional 
pathology of the shoulder, including rotator cuff tears.  There is limited published, large-scale, long-term peer-reviewed literature that shows an open partial 
claviculectomy (Mumford procedure) is an effective and/or safe treatment with concurrent pathology of rotator 
cuff tear/pathology. Moreover, there has been no updated imaging demonstrating the recurrence of the 
mass/cyst. No compelling rationale is presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested procedure, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a claviculectomy procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens (V2784) provided on January 12, 
2023. 
 
You asked the Plan to pay for the polycarbonate lens. You say that the doctor said you needed polycarbonate 
lenses because your left eye is not good and it would provide better protection to your right eye, which is 
blurry. You also say that you believe it should be covered and paid, as you are legally blind and would like to 
protect your only good eye as it is prudent to your health. The Plan denied your request. The Plan says this 
service is not a covered benefit. The Plan also says they spoke with a representative at the provider's office who 
said you were verbally advised of what the charge was for this lens before the order was finalized.  
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. 
 
We looked at the file and the Plan's rules. The record shows that you received a polycarbonate or equal lens, 
which is considered to be an enhancement, and you may purchase this at an additional cost. 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 pay for the polycarbonate lens (V2784) provided on 
January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service August 26, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this was billed with the correct place of 
service and should be paid. The Plan denied your request. The Plan says code 99153 is not payable in the 
facility setting. 
 Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service August 26, 2022, billed 
with code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you will have three or more emergency room 
visits soon. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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 November 12, 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 our policy covers non-emergency ambulance transportation when it is the only way to safely and 
adequately transport a member if other means of transporting a member are unsafe due to a medical condition. 
 
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 sup 
 
port, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via ambulance upon discharge from the hospital was not 
medically necessary.  The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport.  Transportation could have been provided by other 
means (stretcher van) without endangering the enrollee's 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 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 November 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the bifocal lens, and the tint provided on 
November 11, 2022. 
 
You asked the Plan to pay for the deluxe frames, the bifocal lens, and the tint. You say that you are on a fixed 
income, and you cannot afford this bill. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 $400 off the retail price of lenses or contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the claim processed correctly. Based on this 
information, we decided that the Plan's rules for coverage of the deluxe frames, the bifocal lens, and the tint 
have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames, the bifocal 
lens, and the tint provided on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the records do not document the enrollee has lymphedema extending onto the chest, trunk 
and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or 
abdominal lymphedema. There is no documentation that the enrollee has failed to improve with a four-week 
trial as required. There is no documentation that the requested device at issue meets all Medicare criteria. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says the enrollee has severe spinal stenosis, severe facet 
arthropathy, as well as radiculopathy. 
 
The Plan follows Medicare rules. Medicare rules state that procedures such as Intracept are excluded from 
coverage in the presence of primary symptomatic lumbar spinal stenosis. 
 
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 Intracept. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found magnetic resonance imaging 
(MRI) shows lumbar spinal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the triamcinolone acetonide (J3304) and injection (20611) 
provided on December 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the triamcinolone acetonide and injection. The Plan denied your request. The 
Plan says there was no prior authorization on file and a lack of clinical information prior to receiving services. 
 
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 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 triamcinolone acetonide (J3304) and injection 
(20611) provided on December 15, 2022, by an out-of-network (OON) provider.
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. You say that the enrollee is now requiring assists with walker and 
only able to ambulate 50 feet. The enrollee would benefit from therapy services in a IRF in order to return to 
prior level of function. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as at a skilled nursing facility, home with home health services, or home 
with outpatient services. 
 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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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.