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

 
We decided that the Plan does not have to pay for hearing aids purchased from February 14, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you had never received a reimbursement because the 
paperwork had never come and been submitted. The Plan denied your request. The Plan says hearing aids must 
be purchased through the Plan hearing to be covered under the hearing aid services offered by the Plan. 
 
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 with an in-network Plan hearing provider.  
 
We looked at the file and the Plan's rules. The Plan rules say that hearing aids purchased outside of the Plan 
Hearing nationwide network are not covered. The record shows these hearing aids were purchased from an out-
of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids purchased from 
February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code E0675 provided on October 24, 2022. 
 
You asked the Plan to pay for procedure code E0675. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that procedure code E0675 is not covered. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code E0675 based on Medicare criteria. The Plan includes a Local Coverage Article in 
the case file; however, there is no explanation from the Plan referencing what criteria had not been met for 
procedure code E0675. Therefore, we decided that the Plan has to pay for procedure code E0675 provided on 
October 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services provided on 
March 6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the transitional care management services. You say that your provider was the 
only provider available to render the services. The Plan denied your request. The Plan says enrollees must 
receive their care from a network provider.  
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 transitional care management services 
provided on March 6, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 28, 2023. 
 
You asked the Plan to pay for the medication. You say that you were not notified that you would need to pay 
for the medication. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
  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 pay for self-administered drugs provided 
on March 28, 2023.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (97802). 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy (97802).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had a stroke in December of 2022 and need help 
daily activities. 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 complexity of your nursing, medical and rehabilitation can be provided in a 
lower level of care. You do 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 20, 2022, to 
June 19, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA 
and these services were provided in good faith. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 20, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 20, 2022, to June 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 26, 2022, to 
October 25, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you did send in the NOA. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 28, 2022. The NOA was not received by the Plan, so no payment can 
be made on this claim. Although you claim that the NOA was submitted, the Plan has no evidence of receiving 
a NOA from you. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 26, 2022, to October 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90833 billed for date of service December 
14, 2022.  
 
You asked the Plan to pay for procedure code 90833. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 90833 is bundled into payment 
for code 90792. 
 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 90833 
is a column II code to column I code 90792 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 90833 billed for date of service December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rotator cuff repair. 
 
You asked the Plan to pre-approve a rotator cuff surgery. You say that the rotator cuff repair is medically 
necessary. The Plan denied your request. The Plan says more conservative treatment has not been attempted. 
 
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 rotator cuff surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no records the show that there was a recent trial and failure of physical 
therapy noted for shoulder pain. More conservative measures are needed. 
 
 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 rotator cuff surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a rotator cuff repair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the cardiology services provided on April 
18, 2023. 
 
You asked the Plan to reduce the cost share for the cardiology services. You say that you thought that you 
would only have a $45 copayment. 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. Your 
contract with the Plan says that there is a $680 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay $95 
copayment for in-network diagnostic procedures and test provided at an outpatient hospital. 
 
 You have been asked to pay $680, which satisfied the deductible for the cardiology service. The item or service 
you asked the Plan to reduce the cost share for falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $680 deductible which applies to outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time the cardiology services 
was received on April 18, 2023.  
 
You have also been asked to pay a $95 copayment for the cardiology services. You have been asked to pay a 
total of $775 ($680 deductible + $95 copayment = $775). This item/service falls within the 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 reduce the 
cost share for the cardiology services provided on April 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay from October 5, 2022, 
through October 28, 2022. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you cannot afford the copayment you 
have been billed for the SNF stay. 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 $0 
copayment each day for days 1-20 per admission and $150 copayment for each day for days 21-100 per 
admission. 
  You have been asked to pay a total of $450 for the SNF stay. You were billed $0 for dates of services October 
5, 2022, to October 24, 2022 and from October 25, 2022, to October 28, 2022 (date of discharge) you were 
billed $150 per day x 3 days = $450. The SNF stay falls within the Skilled Nursing Facility (SNF) 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 the SNF stay from October 5, 2022, through 
October 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 14, 2022. 
 
You asked the Plan to pay for the home health services. You say that you believe your NOA was filed timely. 
There was a system issue with your provider information in the system that caused the initial claim to reject. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 14, 2022. The NOA was not received by the Plan until May 31, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer system implantable pulse generator 
(0408T, C1824). 
 
You asked the Plan to pre-approve the Optimizer system implantable pulse generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 the Optimizer system implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that cardiac contractility modulation (CCM) remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
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 Optimizer system implantable pulse generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer system implantable pulse generator 
(0408T, C1824).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 1, 
2022, to October 15, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an NOA was not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The file does not show that an NOA was submitted. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health care billed for dates of service October 1, 
2022, to October 15, 2022.
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 is now clinically stable for 
discharge to an LTACH and requires close monitoring to maintain stability and safety. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 there are no services that the enrollee requires that are not currently available. 
Continued care in the short-term acute hospital is appropriate until acute care is no longer required, at which 
time the enrollee is able to be transferred to a lower 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x8). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x8).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface 
application (0394T), therapeutic radiology simulation-aided field setting; simple (77280) and therapeutic 
radiology simulation-aided field setting; complex (77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that the enrollee is in need of this 
outpatient procedure. Medical records are attached to support medical necessity. The Plan denied your request. 
The Plan says a review of current medical literature does not consider this service to be standard medical 
treatment for the enrollee's condition. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the high dose rate electronic brachytherapy with therapeutic radiology simulation-
aided field setting is not a standard of care for such skin tumors. There are insufficient long-term efficacy and 
safety data to support the routine use of electronic surface brachytherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high dose rate electronic brachytherapy, skin surface application (0394T), 
therapeutic radiology simulation-aided field setting; simple (77280) and therapeutic radiology simulation-aided 
field setting; complex (77290).