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

 
We decided that the Plan does not have to pay for the eyewear provided on February 12, 2023. 
 
You asked the Plan to pay for the eyewear. You say that you did not use your benefit in 2022 and assumed it 
would be available in 2023. The Plan denied your request. The Plan says the benefit maximum has been 
reached. 
 
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 up to a $200 maximum, every 24 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the allowance for vision items on July 24, 
2021, which exhausted the benefit. 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 
provided on February 12, 2023.  
 
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 3, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the services provided should be covered 
under the authorization that the facility received. 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the nursing facility care provided on February 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an EpiSwitch Checkpoint inhibitor Response Test (CiRT) 
(81479) provided on April 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the requested testing is payable by Medicare 
and they were denied as experimental in error. Medical records are attached for review. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Per the DEXTM Diagnostics Exchange Registry, this testing has been evaluated by the 
MolDX Program and is considered non-covered at this time. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for an EpiSwitch Checkpoint inhibitor Response Test (CiRT) (81479) provided on April 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services billed for date of service November 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services are payable. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 15% of the total cost for each Medicare-covered lab service.  
 
The enrollee has been asked to pay 15% of the total cost for each Medicare-covered lab service. The services 
fall within the outpatient diagnostic tests benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for the lab 
services billed for date of service November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2023. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for this service. 
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 an office visit provided 
on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator . You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy will be denied as not reasonable and necessary. 
 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 home ventilator. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode which 
could be provided by a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
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 it is medically necessary for the enrollee to recover 
from their procedure and gain full function of their shoulder and arm. The Plan denied your request. The Plan 
says the enrollee must complete their full course of acute hospital treatment.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit on January 2, 2023, provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for  the home visit provided by an OON provider. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
 
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. The Plan requested an Appointment of Representative Form and/or a 
Business Agreement but no response was received. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the home visit provided by 
an OON provider have been met. Therefore, we decided that the Plan does not have to pay for  the home visit 
on January 2, 2023, provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography (93307) provided on December 24, 
2022. 
 
You asked the Plan to pay for the echocardiography. You say that you have submitted documentation to 
support the patient's hospice termination date. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on December 23, 2022. The service in question was provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an echocardiography 
(93307) provided on December 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aqua therapy. 
 
You asked the Plan to pre-approve aqua therapy. You say that your primary care physician (PCP) and specialist 
both agree that this is good therapy for you. You also say that this can aid in your movement. The Plan denied 
your request. The Plan says there was no prescription for aqua therapy provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 aqua therapy have been met. The file does not show there is an order for aqua therapy, specifically, only physical therapy. Without a physician order, 
the requested therapy cannot be approved. Therefore, we decided that the Plan does not have to pre-approve 
aqua therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental consultation 
 
You asked the Plan to pre-approve the dental service. You say that you would like the surgery to be covered as 
in-network. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental benefits.  
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the dental 
consultation
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on February 27, 2023. 
 
You asked the Plan to pay for the refraction . You say that the refraction was necessary to see if you needed 
glasses.  The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service when the eye refraction for eyeglasses/contact lenses is performed during 
a routine vision exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed during a routine 
examination. The record shows you were seen for a follow-up visit for a corneal transplant, which is medical in 
nature. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on February 7, 2023. 
 You asked the Plan to pay for the refraction. You say that you were under the assumption that this service 
would be covered. You say you have several issues with your eyes that must be checked by an 
ophthalmologist. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
 
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 performed as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed during a routine eye 
exam. The record shows diagnoses for pre-glaucoma, cataracts, vitreous degeneration, dry eye, and migraines, 
which makes the eye exam medical in nature. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 12, 2023. 
 
You asked the Plan to pay for dental services. 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 pay for dental 
services provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve closed monitoring telehealth services to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the telehealth services. You say that the enrollee believes they will 
significantly benefit from remote patient monitoring and chronic care management services. The Plan denied 
your request. The Plan says the provided documentation does not clearly show why these services are 
necessary. The Plan also says telehealth services are not covered out-of-network. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
closed monitoring telehealth services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve zoledronic acid (J3488). 
 
You asked the Plan to pre-approve zoledronic acid. The Plan denied your request. The Plan says the requested 
drug is being supplied by pharmacy and administered in home health service, long term care, or skilled nursing 
facility. The Plan also says this request does not meet the definition of the 'Incident To requirements, as it is 
not being furnished by a physician, and is not covered under the member's Part B benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve zoledronic acid (J3488).
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 need assistance because you live alone and 
cannot walk. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be met at an alternate 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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered 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 the pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81432, 81433). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the records do not show that you have any history 
of cancer. The request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 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 genetic testing have been met. The 
records show that several attempts were made requesting medical records, and they were not received. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (81432, 81433).