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

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on March 23, 2023, by an 
out-of-network (OON) provider.  
 
  You asked the Plan to pay for the eye exam. You say that the enrollee was in a nursing home setting at the time 
services were rendered, and they could not choose an in-network optometrist. You also say that the provider 
has no knowledge of which patients they will see until they arrive at the facility. The Plan denied your request. 
The Plan says this service was rendered by an OON provider, and prior authorization was not obtained for the 
service. 
 
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 eye exam (92014) provided on March 23, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device (Vertiflex procedure). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the Veriflex procedure is appropriate 
and much less invasive. The Plan denied your request. The Plan says the Vertiflex procedure is considered 
experimental and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex device is experimental, and more research is needed 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device 
(Vertiflex procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need this benefit due to your health 
conditions of high blood pressure, chronic obstructive pulmonary disease (COPD), and bi-polar. You also say 
that you depend on the $50 for paying your bills. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met.  
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty procedure. 
 
You asked the Plan to pre-approve an abdominoplasty. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says this procedure is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an abdominoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided does not contain primary source documentation that the enrollee 
has intertrigo or functional limitations that are refractory to conservative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an abdominoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an abdominoplasty procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83516, 86146, 86147) provided on July 
12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
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 includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services (83516, 86146, 86147) 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frame (V2025) provided on February 18, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the deluxe frame. You say that some of this claim should be covered. The Plan 
denied your request. The Plan says the treating provider is OON with the Plan, and there is no coverage when 
services are rendered by a non-participating 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 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 deluxe frame (V2025) provided on February 
18, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measles, mumps and rubella (MMR) virus vaccine 
(90707) provided on December 16, 2021. 
 
You asked the Plan to pay for the MMR vaccine. You say that this should be covered. You say that the 
American Journal of Medicine related document indicates that this aids in reducing the severity of COVID-19. 
You also say that you had a friend who had measles. The Plan denied your request. The Plan says the MMR 
vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the MMR vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the MMR vaccine. 
Therefore, we decided that the Plan does not have to pay for the measles, mumps and rubella (MMR) virus 
vaccine (90707) provided on December 16, 2021.  
 Benefits for the MMR vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive metabolic panel (80053), electrocardiogram (93005), 
routine venipuncture (36415), and complete blood count (85025) provided from January 5, 2023 to January 6, 
2023. 
 
You asked the Plan to pay for a comprehensive metabolic panel, electrocardiogram, routine venipuncture, and 
complete blood count. You say that the services are necessary. The Plan denied your request. The Plan says 
that based on the documentation provided, coverage criteria has not been met. 
 
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 80053, 93005, 36415, 85025 is a comprehensive metabolic panel, electrocardiogram, routine 
venipuncture, and complete blood count 
 
We asked our coder 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 a comprehensive metabolic panel, electrocardiogram, routine 
venipuncture, and complete blood count. Our reviewer says that the services are medically necessary. Our 
reviewer found the procedures in question are supported by the documentation for the date of service in 
question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a comprehensive metabolic panel, electrocardiogram, routine venipuncture, and 
complete blood count have been met. Therefore, we decided that the Plan has to pay for a comprehensive 
metabolic panel (80053), electrocardiogram (93005), routine venipuncture (36415), and complete blood count 
(85025) provided from January 5, 2023 to January 6, 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: 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 the enrollee needs aggressive inpatient rehabilitation 
to achieve the highest level of function and ability.  The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met in another setting.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is an excellent candidate for IRF 
services as they are expected to make measurable functional gains as well as improve their medical status 
within a reasonable period sufficient for a safe discharge home. The Plan denied your request. The Plan says 
based on Medicare guidelines, the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are necessary because you are in 
constant acute pain. You also say you have worked with your pain management provider but have gotten no 
relief and the pain is getting progressively worse. The Plan denied your request. The Plan says the requested 
IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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. 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 to pre-approve. Our reviewer says that 
the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. 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 to pre-approve 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87801, 87798, 87481) provided on 
October 6, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial, and you have 
submitted medical records that will show the medical necessity of the services rendered. The Plan denied your 
request. The Plan says a review of the medical literature and clinical practice guidelines do not support PCR 
testing as a first line approach for evaluation of onychomycosis and it is not widely accepted as standard of 
care. The Plan is unable to approve the request for the Dermatomycosis Panel, as the testing is not medically 
necessary, and the requested testing exceeds the enrollee's medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is well established in the medical documentation that this enrollee was suffering with a thick 
painful toenail that demonstrate subungual detritus. A toenail specimen from the left hallux was taken and sent 
for PCR testing to evaluate for pathogens. Medicare guidelines advise that they will indeed pay for items or 
services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve 
the functioning of a malformed body member. These services must be safe and effective, not mainly for the 
convenience of the enrollee or the physician, not experimental or investigational, appropriate in that they 
should be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of 
the enrollee's condition, furnished in a setting appropriate to the enrollees medical needs and condition, one 
that meets but does not exceed the enrollee's medical need, and at least as beneficial as existing and available 
medically appropriate alternatives. The longstanding standard of care for the evaluation of fungus in toenails is 
the performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollee's toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, it is the reviewers opinion that the PCR testing of this enrollee's left hallux 
toenail was not medically reasonable or necessary 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 laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87801, 87798, 87481) provided on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6750) for teeth 12, 14, 10, 7, 21 and 
19 and pontic (D6240) for teeth 13, 6, 8, 9 and 20. 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says to approve a bridge, you must be missing only one upper front tooth or 
only two lower front teeth. The two lower front teeth must be next to each other. You also cannot be missing 
any of your back teeth. Our dentist looked at the x-rays your dentist sent us and said you are missing other 
teeth. 
 
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. The Plan covers retainer 
crown and pontic when the services are medically necessary and reasonable.  
 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 retainer crown and pontic. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found a review of the documentation 
indicates that this treatment plan lists teeth that are not present as abutment retainers and replaces teeth that are 
present. The plan may consider fixed bridges to replace a single missing maxillary anterior tooth or two 
adjacent mandibular anterior teeth when there are no missing posterior teeth. This treatment plan is not 
medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown (D6750) for teeth 12, 14, 10, 7, 21 and 19 and pontic (D6240) 
for teeth 13, 6, 8, 9 and 20.