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

 
We decided that the Plan does not have to pay for computerized corneal topography (92025), an office visit 
(99214), a gonioscopy (92020), ophthalmoscopy (92201), internal eye photography (92286), a diagnostic 
ophthalmic ultrasound (76512) for the left eye and the right eye provided on November 1, 2022. 
 You asked the Plan to pay for computerized corneal topography (92025), an office visit (99214), a gonioscopy 
(92020), ophthalmoscopy (92201), internal eye photography (92286), a diagnostic ophthalmic ultrasound 
(76512) for the left eye and the right eye. You say that it is clear that the enrollee had primary coverage through 
the Plan on this date of service. The Plan denied your request. The Plan says they did not receive a primary 
carriers Explanation of Benefits (EOB). The Plan also says that they verified on July 12, 2023, that the 
enrollee had another insurance carrier as primary from September 01, 2021, to current. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has verified who 
is the primary insurer. As the secondary insurer, the Plan cannot be held responsible for computerized corneal 
topography (92025), an office visit (99214), a gonioscopy (92020), ophthalmoscopy (92201), internal eye 
photography (92286), a diagnostic ophthalmic ultrasound (76512) for the left eye and the right eye until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for computerized corneal topography (92025), an office visit (99214), a gonioscopy (92020), 
ophthalmoscopy (92201), internal eye photography (92286), a diagnostic ophthalmic ultrasound (76512) for 
the left eye and the right eye provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve the foot orthotics. You say that you have a dull, aching, burning, stabbing 
pain mostly on your right foot. You also say that your physician submitted authorization for foot orthotics 
which are considered medically necessary to relieve the pain. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
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.   
 
Records show that you do not suffer from 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 (L3000).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428 x120, 
A0425 x120). 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. Routine transportation 
benefit does not cover ambulance. 
 
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 pre-approve non-emergency ambulance services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) ere contraindicated for this enrollee. The documentation does not support that the enrollee 
needs the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance 
can provide for safe transport. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency ambulance services (A0428 x120, A0425 x120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 2, 2023, to 
January 9, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the acupuncture services for chronic low back pain 
is covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Medicare would only cover acupuncture services if 
you have chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture 
services provided on January 2, 2023, to January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns-porcelain fused to predominantly base 
metal for teeth number 28 and 29 (D2751 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items was exhausted on date of service June 7, 2023.  
  
 
 
 
 
 
 
Specifically, the Plans contract states that two dental crowns are covered per year. You previously received a 
dental crown for teeth number 4 and 5 on June 7, 2023, which were paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for requested dental items. Therefore, we decided that the Plan does not have to 
pre-approve dental crowns-porcelain fused to predominantly base metal for teeth number 28 and 29  
(D2751 x 2).
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 not safe to be home or in a community 
environment. The Plan denied your request. The Plan says the enrollee's records do not show the need for an 
intensive team for care. The Plan says that the services needed may be provided safely in a lower level of care.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shar for Part B drugs and x-rays on May 17, 2023. 
 
You asked the Plan to waive the cost shar for Part B drugs and x-rays. You say that you feel that you should 
not owe anything more than your agreement. 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 20% 
coinsurance for each Medicare-covered Part B drug. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. You must pay a $35 per day, per provider, for Medicare-covered x-ray 
services. Covered services include but are not limited to x-rays. The provider billed in the amount of $1,200 
and the allowed amount is $276 for the service. $276 x 20% = $55.20. There provider billed in the amount of 
$3,015 and the allowed amount is $26.54. This is less than the copayment amount. For both services it's, 
$55.20 + $26.54 = $81.74. Therefore, results in the total cost shairng amount of $81.74. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and $26.54 copayment, which is less than the 
copayment for x-rays. This item/service falls within the Medicare Part B prescription drugs and outpatient 
diagnostic tests and therapeutic services and supplies 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 shar for Part B drugs and x-rays on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth home visit provided on May 23, 2023. 
 
You asked the Plan to pay for the telehealth home visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth home visit 
provided on May 23, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of kyphoplasty in the setting of multiple 
etiologies for pain seen on imaging, have not been demonstrated in the peer-reviewed literature.  
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T12 kyphoplasty. Our reviewer says 
that the enrollee meets the criteria for coverage. Our physician reviewer found the enrollee has had 
conservative therapy without relief and the compression fracture is associated with at least 25% loss of 
vertebral height. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have been met. Therefore, we decided that the Plan has to pre-
approve T12 kyphoplasty (22513).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (procedure code 81345) provided on March 28, 
2023. 
 
You asked the Plan to pay for the lab services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (procedure code 81345) provided on March 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on June 20, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance. This item/service 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 ambulance provided on 
June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bag hook (K0108) and attendant control (E2331). 
 
You asked the Plan to pre-approve a bag hook and attendant control. You say that the items should be covered. 
The Plan denied your request. The Plan says an attendant control cannot be covered in addition to a 
beneficiary-operated joystick and a bag hook does not serve a medical purpose.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bag hook (K0108) and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheostomy supplies provided on April 21, 2023. 
 
You asked the Plan to pay for the tracheostomy supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the tracheostomy 
supplies provided on April 21, 2023.
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 has only gotten some physical therapy at 
the hospital. You say that the enrollee is not able to get around without assistance. The Plan denied your 
request. The Plan says an 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 26, 2022. 
 
You asked the Plan to pay for wound care. You say that you say that the claim was denied due to needing 
medical records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
December 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab, gemcitabine and carboplatin. 
 
You asked the Plan to pre-approve the drugs. The Plan denied your request. The Plan says pembrolizumab, 
gemcitabine and carboplatin are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs. Our reviewer says that 
pembrolizumab, gemcitabine and carboplatin are not medically necessary. Our physician reviewer found that 
the requested use of pembrolizumab, gemcitabine and carboplatin are not FDA-approved. The requested drugs 
are also not supported by one of the major drug compendia or by clinical research.  
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab, gemcitabine and carboplatin.