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

 
We decided that the Plan does not have to pay for the progressive lenses and the deluxe frames provided on 
January 16, 2023.  
You asked the Plan to pay for the progressive lenses and the deluxe frames. You say that you understand that 
the provider was out-of-network and are requesting an exception to be allowed to continue to receive their 
services. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lenses and the deluxe frames have 
not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses and the 
deluxe frames provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on January 5, 2023, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyewear. You say that you were not made aware that you do not have OON 
benefits for vision. You also say that you were not advised that the treating provider is non-participating with 
the Plan, and you would like your money back. The Plan denied your request. The Plan says this eyewear was 
purchased from a provider who is not in the Plan's network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan-approved Provider. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received this eyewear from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on January 5, 2023, 
from an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 6, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
taken to the emergency room by your son's vehicle. You also say that you feel this ambulance service with no 
transport was necessary to your life. The Plan denied your request. The Plan says you refused transport on the 
date of service in question and signed the refusal. The Plan also says this claim processed correctly according 
to the contract and Medicare guidelines and there was no plan error. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 6, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp cap - indirect (excluding final restoration) 
(D3120). 
 
You asked the Plan to pre-approve the pulp cap - indirect. The Plan denied your request. The Plan says this 
service is not covered under the benefit plan. 
 
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 pulp 
cap - indirect (excluding final restoration) (D3120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prefabricated post and core (D2954) and the 
endodontic therapy (D3330) for tooth #3 provided on January 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you needed a root canal procedure done 
and you would like the Plan to cover the dental expenses. The Plan denied your request. The Plan says your 
annual dental maximum benefit for the year has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid $1,026 for dental services on February 7, 2023, which was processed prior to this claim. 
On January 10, 2023, the Plan reprocessed the claim and paid $974 for dental services. For the year of 2023 the 
Plan paid $2,000 ($1,026 paid + $974 paid) for dental services; therefore, your annual dental maximum benefit 
for the year of 2023 was exhausted on the date of services of January 10, 2023. Therefore, we decided that the 
Plan does not have to pay more for the prefabricated post and core (D2954) and the endodontic therapy 
(D3330) for tooth #3 provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the records do 
not support the services. 
 
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 99490 is not supported in the medical record. Specifically, the records provided do not 
include a face-to-face initiating visit with the enrollee. 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 99490 billed for date of service January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical indications.  
 
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 requested device. Our physician 
reviewer found that the enrollee has diabetes. The record does not indicate that the enrollee is being treated 
with insulin or has problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 13, 2023. 
 
You asked the Plan to pay for lab testing. You say that you believe the services are medically necessary. 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 lab testing provided on 
February 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are 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 intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back in this enrollee is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) 
purchased on January 23, 2023. 
 
You asked the Plan to pay for the eyewear. You say that you did not realize it was a 12 month per claim for 
eyeglasses, you thought it was by calendar year. You also say that your last claim was for frames, and prior to 
that for sunglasses as requested by your eye doctor. The Plan denied your request. The Plan says the maximum 
allowance for vision services has already been paid by the Plan, and no further payment is due to you. 
 
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 you up to $250 once every 12 months towards the cost of eyewear. 
 We looked at the file and the Plan's rules. The record shows that the Plan paid for eyewear on June 11, 2022, 
and September 23, 2022, and your eyewear allowance has been exhausted. You will not be eligible for eyewear 
reimbursement until June 2023. Based on this information, we decided that the Plan's rules for coverage of the 
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) 
and progressive lenses (V2781) purchased on January 23, 2023.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the LTACH admission 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 all medically necessary care is being provided in the current acute care setting.  
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 Plan. The 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 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: 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 you need rehab to help with increasing the strength 
in your legs in order to get back to your previous levels. The Plan denied your request. The Plan says you must 
complete your full course of acute hospital treatment. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be held responsible since you did not call and were not transported. The Plan denied your request. The Plan 
says the medical records confirm that you refused transport on the date of service in question, and you signed 
the refusal. The Plan also says this claim processed correctly according to the contract and Medicare guidelines 
and there was no plan error. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on November 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should be reimbursed. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The records do not show that the provider received a temporary license during the public health 
emergency. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 15, 2022, to 
May 2, 2022. 
 You asked the Plan to pay for the home health services. You say that you never received a denial on your first 
claim submission. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 15, 2022. The NOA was not received by the Plan until July 7, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
April 15, 2022, to May 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2042 billed for date of service July 1, 2022, 
to July 31, 2022. 
 
You asked the Plan to pay for procedure code T2042. You say that the billed code is valid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code T2042 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2042 billed for date of service July 1, 2022, to July 31, 2022.
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 the denial, based on 
medical necessity. The Plan denied your request. The Plan says that enrollee can continue to receive the current 
acute care needs at the current acute care setting which is already approved by the health plan. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care.  
  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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 has always been independent needing no 
assistance with a cane, walker, or wheelchair and you are afraid in their weakened condition their decision-
making skills may be slightly impaired to the point that they do not realize the enrollee's not quite back to their 
baseline. The Plan denied your request. The Plan says the enrollee's needs can be met in an alternate level of 
care. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have 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 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 enrollee has ongoing acute medical issues and still requires acute care 
services. 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. 
 
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.