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

 
We decided that the Plan does not have to pay for the frames (V2020) and eye refraction (92015) provided on 
November 8, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the frames and eye refraction. You say that the treating provider does not know 
which patients they will be seeing since they are assigned to a facility and given a chart of patients in need of 
their services. You also say that the provider believes that all patients assigned have active coverage and the 
provider will be fully reimbursed. The Plan denied your request. The Plan says the treating provider was OON 
with the Plan. 
 
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 frames (V2020) and eye refraction (92015) 
provided on November 8, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) 
purchased on July 14, 2022. 
 
You asked the Plan to pay for the deluxe frames and progressive lenses. You say that you need these glasses for 
reading and driving. The Plan denied your request. The Plan says you exceeded your benefit limit. 
 
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 will reimburse up to $90 per calendar year for eyewear purchased from a non-participating 
provider.  
We looked at the file and the Plan's rules. Specifically, the record shows that you exceeded your benefit limit as 
you had purchased frames and lens from an out-of-network provider on January 22, 2022, which was 
processed, and you were issued a $90 reimbursement on March 24, 2022. Based on this information, we 
decided that the Plan's rules for coverage of the deluxe frames and progressive lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses 
(V2781) purchased on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provider 
documented a previous epidural steroid injection but did not provide any details as to when this was done, the 
percentage and duration of pain relief, or at what level of the lumbar spine the ESI was done. In addition, there 
was no evidence of conservative care, such as physical therapy, to attempt treatment of the pain before 
proceeding to the ESI. The review has determined that the enrollee does not meet the coverage criteria detailed 
in the LCD. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is the superior 
modality to accurately and safely treat the enrollee. The Plan denied your request. The Plan says this is 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while normal tissue exposures are often less with proton therapy to demonstrate need, 
proton therapy plans should meet accepted dosimetric constraints while the non-proton plans do not. Simply 
showing a reduction in normal tissue exposure does not demonstrate medical necessity. While there are comparisons for this enrollee, it is not evident that proton therapy is needed over a well-designed non-proton 
plan. Thus, proton therapy would not be within accepted standards 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical disc replacement. 
 
You asked the Plan to pre-approve cervical disc replacement. 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 follows Medicare rules. Medicare rules say that cervical disc replacement is covered when specific 
criteria are met. 
 
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 cervical disc replacement. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found cervical disc replacement 
surgery combined with fusion is experimental. 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 cervical disc replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cervical disc replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 17, 2021, billed 
with codes 81201, 81317, 81408, and 81407. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. The 
panel testing was not billed with a single panel code as required. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on February 17, 2021, billed with codes 81201, 81317, 81408, 
and 81407.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service November 
14, 2022. 
 You asked the Plan to pay for the billed services. You say that the procedure was rendered in the appropriate 
place of service. The Plan denied your request. The Plan says the code is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 was provided in a hospital outpatient place of service. No payment is recognized 
for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 85060 billed for date of service November 14, 2022.
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 IRF services to gain maximum mobility. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 8 additional 
physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The enrollee has no recent injury or a 
decline in function. The additional therapy services are not appropriate duration and frequency for treatment of 
the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217). 
 
You asked the Plan to pay for a pneumatic compression device and water circulating heat pad with pump. You 
say that the items are medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis and a water 
circulating heat pad is not medically necessary. 
 
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. If code E0215 or 
E0217 is provided it will be denied as not reasonable and necessary. 
 
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. A water circulating heat pad is not medically necessary. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and 
water circulating heat pad with pump (E0217).
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 are requesting reconsideration stating the 
enrollee's clinical condition meets full inpatient acute rehabilitation criteria and a lower level of care cannot 
provide the care needed. The Plan denied your request. The Plan says 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010). 
 
You asked the Plan to pre-approve dental implants. 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 
dental implants (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that you are requesting a therapeutic CGM for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not require insulin three or more 
times daily. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture and travel 
allowance (P9603, 36415) provided on December 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the blood collection. The Plan denied your request. The Plan says this service is 
not covered OON. 
 
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 collection of venous blood by venipuncture 
and travel allowance (P9603, 36415) provided on December 5, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 22, 2020, to 
February 1, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee experienced hypoxia which required additional care. The Plan denied your request. The Plan says the 
medical records do not support the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with J96.01, defined as acute respiratory failure with hypoxia. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the emergency room with 
shortness of breath. The chest X-ray was consistent with bilateral pleural effusions and her labs showed an 
increased brain natriuretic peptide (BNP) level suggestive of fluid overload and congestive heart failure. 
Although acute respiratory failure is characterized by life-threatening derangements in arterial blood gases and 
acid-base status, the manifestations of chronic respiratory failure are less dramatic and may not be as readily 
apparent. In this case, the documentation supported an admission for acute systolic congestive heart failure. 
Even though acute respiratory failure with hypoxia is documented, supporting documentation was not found 
within the submitted medical record. The review has determined that the documentation did not support 
diagnosis code J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 22, 2020, to February 1, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which states these services are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a surgical repair procedure provided on 
January 11, 2023. 
 
You asked the Plan to reduce the coinsurance for a surgical repair procedure. You say that you think that this 
provider is in-network. 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 50% 
coinsurance for out-of-network surgery services performed at a specialists office. 
 
You have been asked to pay 50% coinsurance for a surgical repair procedure. This item/service falls within the 
out-of-network surgery services performed at a specialists office 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. The total you owe is $230.71 ($461.43 allowed 
amount x 50% = $230.71 rounded down). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for a surgical repair procedure provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the astigmatism correcting function of intraocular lens. 
 
You asked the Plan to pre-approve the astigmatism correcting function of intraocular lens. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve the astigmatism 
correcting function of intraocular lens.