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

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on February 22, 2023. 
 
You asked the Plan to pay for the eye exam. You say that you want to file an appeal against the $30 copay 
because to your knowledge you get a free eye exam every year and you do not see why there would be a $30 
copay. You also say that you had to get a retinal eye exam and thought everyone does that with an eye exam. 
The Plan denied your request. The Plan says it has been determined that you will remain liable for the $30.00 
copayment applied for the medical eye exam performed on February 22, 2023. 
 
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. 
 
 We looked at the file and the Plan's rules. The record shows that you received a medical eye exam, and not a 
routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye exam 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92004) provided 
on February 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fusion of a finger joint (26860) and fusion of a finger 
joint add-on (26861) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve fusion of a finger joint and fusion of a finger joint add-on to be provided by 
an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there 
are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
fusion of a finger joint (26860) and fusion of a finger joint add-on (26861) to be provided by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88334 billed for date of service December 7, 
2022.  
 
You asked the Plan to pay for procedure code 88334. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88334 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
provided, correctly coded, and medically necessary. Based on this information, we decided that Medicare rules 
for coverage of procedure code 88334 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88334 billed for date of service December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0650, E0673, E1399, and 
97760). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare coverage criteria 
were not met as this device is not covered for prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 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 prevention of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0650, E0673, E1399, and 97760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0457). 
 
You asked the Plan to pay for a back brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a physician order or relevant medical records which support medical necessity for 
the supplies provided in this case. There is no indication a face-to face encounter took place within 6 months of 
the order. There was no order or medical records submitted from the enrollee's treating physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for a back brace (L0457).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that it does not make sense that the insurance 
approved the service but not the transportation. The Plan denied your request. The Plan says the retested 
transportation was for 147 miles and therefore exceeds the limit of the supplemental benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the record shows 
that the destination you would like to be transported to is more than 50 miles from your residence. Therefore, 
we decided that the Plan does not have to pre-approve additional mileage.
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 this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, the member does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. Therefore, the denial is upheld. Skilled therapies at 
home or at a skilled nursing facility may be approved upon request. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria, and the enrollee 
is able to participate in the intensive therapy regimen. The Plan denied your request. The Plan says the IRF care 
is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility. 
 
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 has cognitive impairment, double vision. The enrollee is functionally 
impaired at the contact guard to stand with assistance. The enrollee does not require intensive or complex 
rehabilitation nor frequent physiatry oversight. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the over-the-counter (OTC) items purchased on March 
9, 2023. 
 
You asked the Plan to pay more for the OTC items. You say that you had the money available on your OTC 
card, and you purchased a supplement and some vitamins. The Plan denied your request. The Plan says you 
exceeded the remaining $32.16 in the amount of $2.32 when you made the purchase on March 9, 2023, in the 
total amount of $34.48. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, however, the 
Plan offers a $70 quarterly allowance for eligible over-the-counter (OTC) items. The record shows that you 
exhausted your quarterly OTC allowance with this purchase on March 9, 2023. Therefore, we decided that the 
Plan does not have to pay more for the over-the-counter (OTC) items purchased on March 9, 2023.
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. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for myocardial infarction. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 64.2 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar facet nerve injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee had 80% pain relief post procedure 
from their medial branch block on August 16, 2022, and 80% pain relief post procedure for their second medial 
branch block on August 30, 2022. The Plan denied your request. The Plan says that a lumbar facet nerve 
injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the 
enrollee does meet the coverage criteria. Our physician reviewer found that the two sets of a medial branch 
nerve block (MBB) that were performed produced an 80% pain relief for the enrollee. Therefore, the request is 
medically reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve a lumbar facet nerve injection.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gas permeable contact lenses (V2531) provided on 
January 11, 2023. 
 
You asked the Plan to pay for the gas permeable contact lenses. The Plan denied your request. The Plan says 
contacts are not a covered benefit on your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the gas permeable contact lenses (V2531) provided on January 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth evaluation provided on September 08, 2022. 
 
You asked the Plan to pay for the telehealth evaluation. You say that the services were provided in good faith. 
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 telehealth evaluation 
provided on September 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on November 22, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the x-ray. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says that this service was 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 a chest x-ray provided on November 22, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the administration. We decided that the Plan does 
not have to waive the cost sharing for the injection.  
 You asked the Plan to waive the cost sharing for the daratumumab injection, and the administration provided 
on February 22, 2023. You say that you should not have any cost sharing for these services. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost sharing for the administration.  
 
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 says that you pay no additional cost for 
the administration of Part B drugs. The Plan says you must pay a 20% coinsurance for the administration. 
Based on the Plan contract, however, you cannot be asked to pay any cost-sharing for the administration of Part 
B drugs. Therefore, we decided that the Plan has to waive the cost sharing for the administration.  
 
We also decided that the Plan does not have to waive the cost sharing for the injection. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for in-network Medicare Part B covered drugs provided in all places of service. 
 
You have been asked to pay a $972.79 coinsurance for the injection because the Plan is only holding you 
responsible for this amount which is less than the 20% coinsurance. This item/service falls within the Medicare 
Part B prescription drugs benefit category. 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 sharing for the 
injection. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote cardiac monitoring provided on December 14, 
2022. 
 
You asked the Plan to pay for the remote cardiac monitoring. You say that you rendered services in good faith. 
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 remote cardiac 
monitoring provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a specialist office visit. You say that this service is medically necessary. The 
Plan denied your request. The Plan says that this service can be provided by an in-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 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 specialist office visit to be provided by an OON provider.