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

 
We decided that the Plan does not have to pre-approve a breast thermography (93740). 
 
You asked the Plan to pre-approve a breast thermography. You say that the requested service is a necessity for 
your care. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that thermography for any indication is excluded 
from Medicare coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breast thermography have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a breast thermography (93740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexwave Device. 
 
You asked the Plan to pre-approve Nexwave Device. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TENS units are only covered for certain 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 Nexwave Device. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found you have chronic low back pain. Your medication trials have included Baclofen, 
oxycodone and amitriptyline. You have not had physical therapy. No imaging reports are submitted for review. 
TENS units for low back pain are not covered unless the enrollee is enrolled in a clinical trial. No 
documentation shows that you are in a clinical trial. Therefore, you do not meet criteria for the requested 
device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nexwave Device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Nexwave Device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on April 22, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the 
documentation did not support that the enrollee's condition was such that the time needed to transport the 
enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or 
seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did 
not have adequate facilities to provide the medical services needed by 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on April 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency air ambulance transport, one way, and 
fixed wing air mileage. 
 
You asked the Plan to pre-approve air ambulance services. You say that the enrollee is not able to receive 
access to efficient care for their health needs in their area. You say that the enrollee has had a decline in her 
physical and mental health as a result. You say that the enrollee needs to be moved to a facility closer to family. 
You also say that this is the only way the enrollee can travel. The Plan denied your request. The Plan says non-
emergency air ambulance is only covered to the nearest appropriate facility. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulance transport is covered to the nearest 
appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt 
therapy) as well as the return transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve non-emergency air ambulance transport, one way, and fixed wing air mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), electrical stimulation (97104), and 
therapeutic procedure (97110) provided from August 29, 2023, to September 1, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you expected your insurance to pay for the 
services received from the chiropractor. The Plan denied your request. The Plan says these services are not 
covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203), electrical stimulation (97104), and therapeutic 
procedure (97110) provided from August 29, 2023, to September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal B (90620), Haemophilus influenzae type 
b vaccine (Hib) (90647), inactivated poliovirus vaccine (IPV) (90713), Tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715), Menactra (90734), and their administration (90471, 90472). 
 
You asked the Plan to pay for the vaccine services. You say that you feel these vaccine services should be 
covered as part of your continuing oncology treatment. The Plan denied your request. The Plan says routine 
vaccine services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the meningococcal B (90620), 
Haemophilus influenzae type b vaccine (Hib) (90647), inactivated poliovirus vaccine (IPV) (90713), Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715), Menactra (90734), and their administration 
(90471, 90472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2500) purchased on September 8, 2023, 
from a non-Plan approved vision care provider. 
 
You asked the Plan to pay for the contact lenses. You say that you are appealing this denial because contact 
lenses are a standardized product and not dependent on being supplied in-network or out-of-network. You also 
say that you should not be denied your claim for saving the Plan with securing a lower cost for the exact same 
contact lenses you need based on your eye exam prescription. The Plan denied your request. The Plan says you 
received these contacts from a provider that is not contracted under the Plan's vision network. 
 
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 they are provided by an approved vision care provider. 
 We looked at the file and the Plan's rules. Specifically, the record shows that you purchased these contacts from 
a provider that is not a Plan-approved vision care provider. The contract clearly states that you are responsible 
for all eyewear costs from providers outside of the Plan's approved Vision network. Based on this information, 
we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for the contact lenses (V2500) purchased on September 8, 2023, from a non-
Plan approved vision care 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says acccording to Medicare guidelines, 
admission to acute rehabilitation 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 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. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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 the office visit (99213) provided on July 6, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 
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 office visit (99213) provided on July 6, 2023, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH care. You also 
say that a lower level of care is not suitable and would be a risk to the enrollee's health. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that per review of the provided records, the enrollee's medical needs do not meet the 
requirements for an LTACH admission. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2067 billed for date of service July 10, 
2023. 
 
You asked the Plan to pay for the billed service. You say that other claims paid for the same codes. The Plan 
denied your request. The Plan says payment is not allowed while the enrollee is an inpatient. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 We looked at the file and the rules. The records show that the enrollee was receiving inpatient care at the time 
the services at issue were provided. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. Payment for this service would have been included under the facility claim. Payment to you for 
this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code G2067 billed for date of service July 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on August 11, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided.  Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown-porcelain/ceramic (D2740) provided on September 8, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service 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 item or service was exhausted on date of service December 9, 2021. 
Therefore, we decided that the Plan does not have to pay for crown-porcelain/ceramic (D2740) provided on 
September 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service August 6, 
2023. 
 You asked the Plan to pay for the billed service. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that code 99285 was reimbursed by the Plan on 
August 21, 2023. A comparison of the two claim lines show these are exact duplicates. If more than one 
evaluation and management service is provided on the same day to the same patient by the same, only one 
evaluation and management service may be reported unless the evaluation and management services are for 
unrelated problems. Based on this information, we decided that the Medicare rules for the billed service have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for 
date of service August 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), 
neuromuscular reeducation (97112), and the mechanical traction therapy (97012) provided on June 12, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered by Medicare or 
the Plan.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), 
neuromuscular reeducation (97112), and the mechanical traction therapy (97012) provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 21, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that it had been less than a year since your last eye 
test. You also say you felt that you needed an eye exam sooner as your vision had deteriorated, and you 
suspected a medical issue with your eyes.  The Plan denied your request. The Plan says the benefit maximum 
of one refraction per calendar year has been met for 2023. 
 
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 refractions up to one time every calendar year. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received an eye refraction that was billed 
on March 10, 2023, and was paid in full. The contract clearly states that all subsequent refractions are not 
covered. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on July 11, 2023. 
 
You asked the Plan to pay for the eyewear. You say that when you asked at the second provider's office what 
the cost would be, you were advised there would be no cost for the exam, but you did not ask about another 
pair of glasses. You also say that you were advised it would cost about $300 to put the lens in your own frames. 
The Plan denied your request. The Plan says your eyewear allowance had been exhausted prior to this date of 
service. 
 
 
 
 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 up to $350 per year for eyeglasses and lenses, replacement of frames or lenses, or 
contact lenses. 
 
We looked at the file and the Plan's rules. The record shows that your $350 for eyewear was utilized fully on 
June 21, 2023, per claim ending in *37A8, leaving no amount to be applied to the eyewear you received on 
July 11, 2023. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on July 11, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 14, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you believe that 
you shouldnt have to pay. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room services. This item/service falls within 
the emergency 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 emergency room 
services provided on July 14, 2023.