Persius/hicric huggingface dataset:
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is not stable enough for transfer to 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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the reinstatement of your 2023 vision benefits. 
 
You asked the Plan to pre-approve the reinstatement of your 2023 vision benefits.. You say that you returned 
the contact lenses due to incorrect prescription, confirmed by the provider. You also say the second lenses were 
not right, as they would fog up. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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 one routine eye examination per calendar year. The Plan also covers a $300 benefit 
towards one pair of eyeglasses, or a $0 copayment for two pair of select eyeglasses per Plan year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye examination per 
calendar year. The Plan rules also say that they cover a $300 benefit towards one pair of eyeglasses, or a $0 
copayment for two pair of select eyeglasses per Plan year. This record shows this benefit was exhausted on 
January 18, 2023. Based on this information, we decided that the Plan's rules for coverage of the reinstatement 
of your 2023 vision benefits. Therefore, we decided that the Plan does not have to pre-approve the 
reinstatement of your 2023 vision benefits.  
 
Your complaint about the potentially poor vision care service and potentially not receiving an explanation of 
benefit (EOB) 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: 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 you are appealing this denial. The Plan 
denied your request. The Plan says admission to an LTACH 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 the record indicates the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.   
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is unsafe at home and needs 
rehabilitation. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 12, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not 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 Plan contract says the enrollees POS benefit only applies to 
non-Medicare covered dental services covered by the Plan. 
 
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 
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 provided on June 12, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker. 
 
You asked the Plan to pre-approve a rollator walker. You say that you need this item. The Plan denied your 
request. The Plan says this item has been requested for community use and travel which is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a rollator walker.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 6, 2023. 
 You asked the Plan to pay for procedure code 93010. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says payment for code 93010 is 
bundled into payment for code 31500. 
 
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 93010 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93010 billed for date of service May 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 for date of service March 24, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed are not supported. 
 
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, the CPT Code Manual definition of 
code 99204 is office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. 
 
We asked our physician review 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 procedure code 99204. Our reviewer says 
that the documentation supports the code billed. Our reviewer found the enrollee was referred for a cataract 
evaluation. The documentation supports that the history is medically appropriate. The examination is medically 
appropriate.  Given the enrollee's pseudophakia and floppy iris, the medical decision making is of moderate 
complexity. Therefore, code 99204 is supported as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99204 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99204 for date of service March 24, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the lab services were not 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 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 laboratory services provided on December 9, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer (E0570) provided on May 06, 2023. 
 
You asked the Plan to pay for the nebulizer (E0570). You say that the item should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nebulizer (E0570) 
provided on May 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for levocarnitine and a vitamin B12 injection provided on July 6, 
2023. 
 
You asked the Plan to pay for levocarnitine and a vitamin B12 injection. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says levocarnitine and a vitamin B-12 injection are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for levocarnitine and a vitamin B-12 injection. 
Our reviewer says that levocarnitine and a vitamin B12 injection are not medically necessary. Our physician 
reviewer found that the clinical value and effectiveness of vitamin B12 and levocarnitine in the setting of 
chronic pain have not been demonstrated in the literature. Also, the requested use of levocarnitine and a 
vitamin B12 injection are not FDA-approved for the enrollee's diagnosis. Additionally, levocarnitine and a 
vitamin B12 injection are not supported by one of the major drug compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of levocarnitine and a vitamin B12 injection have not been met. Therefore, we 
decided that the Plan does not have to pay for levocarnitine and a vitamin B12 injection provided on July 6, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a lower limb prosthesis. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there are in network providers that can provide this item. 
 
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 
a lower limb prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on May 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 core 
buildup services (D2950) provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1820). 
 
You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the medical records do not indicate weakness or deformity of the knees. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis with condylar pads and joints 
with or without patellar control (L1820) is covered for ambulatory beneficiaries who have weakness or 
deformity of the knee and require stabilization. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
knee brace (L1820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable underwear (T4541).  
 
You asked the Plan to pre-approve incontinence supplies. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable underwear (T4541).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand rims (K0108). 
 
You asked the Plan to pre-approve hand rims. You say that the item should be covered. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve hand rims (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for arthrocentesis injections and a PT visit 
provided from May 31, 2023, to June 21, 2023. 
 
You asked the Plan to waive the cost share for arthrocentesis injections and a PT visit. You say that you 
disagree with the cost share applied to the services rendered. 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 20% 
coinsurance for Medicare Part B drug injections and a $20 copayment per day for Medicare-covered physical 
therapy services.  
 
You have been asked to pay $175.37 for arthrocentesis injections and a PT visit. This total includes $155.37 
coinsurance, which is 20% of the allowed amount for arthrocentesis injections ($258.93 allowed x 20% = 
$51.79 per injection x 3 injections = $155.37) and a $20 copayment for a PT visit. The arthrocentesis injections 
fall within the Medicare Part B prescription drugs benefit category. The PT visit falls within the outpatient 
rehabilitation services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for 
arthrocentesis injections and a PT visit provided from May 31, 2023, to June 21, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve the CT scan. You say that you are having excessive weight loss and need to 
rule out any life-threatening conditions. The Plan denied your request. The Plan says that the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you have had 20-pound weight loss over the past 
year and thus qualify for the requested CT abdomen and pelvis. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen.  
 
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.