Persius/hicric huggingface dataset:
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 the LTACH services. You say that LTACH services are necessary as an 
admission to a lower level of care would result in an overall decline and lead to another admission to the short-
term acute care hospital. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 that recent notes describe the enrollee as having been extubated tolerating low dose 
oxygen support but still on total parenteral nutrition (TPN) and jejunostomy tube feeds with the chest tube still in use. The enrollee appears to be improving but not yet stable for transfer and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. Transfer to the LTACH is not medically necessary at this time as the 
enrollee not yet stable and as it would not be clinically advantageous at this time.  
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 18, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
on the ground when the ambulance arrived and could not get up. You also say that once they checked your 
glucose and blood pressure you were able to be released. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on October 25, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are 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 G0483 based on Medicare criteria. The Plan states that procedure code G0483 is 
not payable per Local Coverage Determination L36037 and Local Coverage Article A56761. However, review 
of these guidelines found that they do not specifically state that procedure code G0483 is not covered. The Plan 
provided no rationale as to why this code is not covered under these guidelines. Therefore, we decided that the 
Plan has to pay for procedure code G0483 provided on October 25, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested Gelsyn-3 is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Synvisc/Synvisc One first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Orthovisc and Synvisc/Synvisc One. The documentation does not support 
that Orthovisc and Synvisc/Synvisc One would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 24, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the 
ambulance arrived, they were able to revive your wife at the scene. You also say that she started feeling better 
so you decided to decline the transport to the hospital. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination and the refraction 
provided on November 22, 2022. 
 
You asked the Plan to pay for the routine ophthalmological examination and the refraction. You say that you 
were told the provider was in-network. You say the entire cost of your eye exam should be covered. 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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is only in-network for medical vision 
services. This means the provider is considered out-of-network for routine vision services. Based on this 
information, we decided that the Plan's rules for coverage of the routine ophthalmological examination and the 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
ophthalmological examination and the refraction provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 provided on May 23, 2022. 
 
You asked the Plan to pay for procedure code 99490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of procedure code 99490 have been met. 
In this case, the appellant has not provided supporting documentation of the billing provider having an 
initiating face-to-face visit separate of the chronic care management (CCM) service. This face-to-face visit is 
not part of the CCM service and can be separately billed to the physician fee schedule (PFS) but is required 
before CCM services can be provided directly or under other arrangements. The billing practitioner must 
discuss CCM with the patient at this visit. Therefore, we decided that the Plan does not have to pay for 
procedure code 99490 provided on May 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
January 23, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were told by 
your doctor to go to the emergency room. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 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 January 23, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services are payable per the guidelines. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on September 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are not used for the prevention of 
deep vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 Transmitter. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that to be eligible for coverage of a CGM and related 
supplies, the beneficiary must meet specific coverage criteria. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes mellitus 
and are not insulin-treated. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 Transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 Transmitter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital care billed for date of service 
December 1, 2022. 
 You asked the Plan to pay for the billed services. You say that the codes are correctly billed. The Plan denied 
your request. The Plan says the services are packaged into payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that codes J1170 and J2405 have a status indicator of N, which means they are packaged services. 
Codes 85025, 80053, 83690, 84484, and 81001 have a status indicator of Q4. These codes are packaged when 
billed with a code that has a status indicator of S, such as code 96374. Code 93005 has a status indicator of Q1, 
which is also packaged when billed with a status indicator of S. 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 
the outpatient hospital care billed for date of service December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2599) purchased on December 26, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the contact lenses. You say that your vision benefits said you had a $300 
maximum benefit coverage amount per year for contact lenses, and no restrictions were provided. You also say 
that you are requesting reimbursement for the Plan allowance. The Plan denied your request. The Plan says you 
purchased the contact lenses from a non-network provider. The Plan also says that the services were not 
authorized by the Plan. 
 
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 rendered by an in-network provider. 
 
 
 We looked at the file and the Plan's rules. The record shows that you purchased these contact lenses from an 
OON provider. 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 (V2599) 
purchased on December 26, 2022, from an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment and injections provided on August 29, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the treatment and injections. You say that reimbursement should be made for the 
services provided and for the services that were authorized. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless pre-authorized.  
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 treatment and injections provided on August 
29, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complicated wounds that 
require continued wound care therapy. You also say without the services provided by the LTACH, the enrollee 
will deteriorate. The Plan denied your request. The Plan says the enrollee does meet Medicare guidelines for 
care in an LTACH. 
 
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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the 
administration of chemotherapy drugs provided on December 7, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the administration of chemotherapy 
drugs. You say that the services received should be fully covered by the Plan. The Plan denied your request. 
The Plan says the cost sharing will be applied according to the Plan contract. 
 
  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 20% 
coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. 
 
You have been asked to pay a coinsurance of $1,500.73 for chemotherapy drugs and the administration of 
chemotherapy drugs. This coinsurance charged is less than the standard amount due to the maximum out-of-
pocket being met. This item/service falls within the Medicare Part B 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 chemotherapy drugs and the administration of chemotherapy drugs 
provided on December 7, 2022.
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. The Plan 
denied your request. The Plan says after receiving skilled services, your medical care can now be provided 
intermittently. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and 
implants (D6111). 
 
You asked the Plan to pre-approve implants and surgical placement. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and implants (D6111).