Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $147 more for the progressive lenses. We decided that the Plan does not 
have to fully pay for the progressive lenses.  
 
You asked the Plan to pay more for the progressive lenses (V2781) provided on March 6, 2023. You say that 
you are appealing this denial for progressive lenses so you could have some coverage for your glasses. The 
Plan says that you exhausted your coverage during the time period. The Plan also says that standard lenses are 
considered single-vision lenses with one prescription, and this service is not covered by the Plan. 
 We decided that the Plan has to pay $147 more for the progressive lenses.  
 
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 up to a $200 for eyewear every year. 
 
We looked at the file and the Plan's rules. The provided documentation does not show that the Plan paid the full 
$200 allowance toward your eyewear purchase. Specifically, the information submitted supports that the Plan 
only paid $53 toward the eyewear provided on March 6, 2023. Your Evidence of Coverage clearly states that 
you have a $200 benefit per calendar year for eyewear. Based on this information, we decided that the Plan's 
rules for additional coverage of the progressive lenses have been met. Therefore, we decided that the Plan has 
to pay $147 more for the progressive lenses.  
 
We also decided that the Plan does not have to fully pay for the progressive lenses. 
 
We looked at the file and the Plan's rules. The record shows that he Plan only paid $53 for this eyewear 
purchased on March 6, 2023, and we have decided that the Plan must pay an additional $147 for the 
progressive lenses. This would exhaust your $200 eyewear benefit. Based on this information, we decided that 
the Plan's rules for additional coverage of the progressive lenses have not been met. Therefore, we decided that 
the Plan does not have to fully pay for the progressive lenses. 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from care in the IRF 
setting.  The Plan denied your request. The Plan says the criteria for this level of care are not met.  
 
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 is an 82-year-old male with a medical history including hypertension and 
chronic back pain with neuropathy and arthritis who was admitted to the hospital for lumbar spine surgery. He 
has remained medically stable and is to wear a back brace when out of bed. He was discharged home on June 
30, 2023, with home health care services. The most recent therapy notes indicate that the enrollee continues to 
require the use of a wheelchair and is non-ambulatory. He is at or near his baseline functional status. 
 
In this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
rehab 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, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for inpatient hospital care provided on November 24, 
2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be 
covered The Plan denied your request. The Plan says that this was not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan failed to provide a valid 2023 Evidence coverage (EOC). Therefore, we 
decided that the Plan has to waive the copayment for inpatient hospital care provided on November 24, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on February 9, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that this should be covered. The Plan denied your 
request. The Plan says this 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 podiatry services provided on February 9, 2023, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the speech therapy services billed with code 92609 for December 13, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the billed diagnosis codes do not fall under the coding and billing requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the billed diagnosis codes do not fall under the coding and 
billing requirements in the Local Coverage Article (LCA); however, the LCA does not explicitly state that any 
code not listed does not support medical necessity or that the billed diagnosis codes do not support medical 
necessity. Therefore, we decided that the Plan has to pay for the speech therapy services billed with code 92609 
for December 13, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 for date of service November 17, 
2022. 
 
You asked the Plan to pay for procedure code 99215. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 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 procedure code 99215. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee had a medical history 
including Opioid dependence, uncomplicated who was evaluated for follow-up and continuation of treatment 
with Suboxone. The documentation did not indicate there were any complications with treatment. The 
documentation does not support medical decision making of high complexity. Therefore, code 99215 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99215 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99215 for date of service November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom oral appliance. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom oral appliance 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that you have a 
diagnosis of sleep apnea. The custom oral appliance is being requested for nighttime teeth grinding (bruxism). 
The criteria for coverage are not met and the custom oral appliance is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom oral appliance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 21, 2022, 
billed with code 99222-AI. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
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 99222-AI is Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 the inpatient hospital care provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical record documents that the 
enrollee was outpatient observation status on date of service billed. There is a more appropriate code to report 
for service provided. In this case, CPT 99222 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital care provided have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided on November 21, 2022, billed with code 
99222-AI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a travel Continuous Positive Airway Pressure (CPAP) 
device. 
 
You asked the Plan to pre-approve a travel CPAP device. You say that the item is necessary. The Plan denied 
your request. The Plan says backup items are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP device. A CPAP device serves the same purpose as a travel CPAP 
device. Therefore, we decided that the Plan does not have to pre-approve a travel Continuous Positive Airway 
Pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the service is medically necessary. 
The Plan denied your request. The Plan says a sacroiliac joint injection 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 a sacroiliac joint injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of lumbar disc disease with lumbar 
radiculopathy, which is not consistent with sacroiliitis. This is not a condition that would generally be 
amenable to treatment with a sacroiliac injection. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care. 
 
You asked the Plan to pre-approve continued inpatient mental health care. You say that the enrollee needs 
continued care. The Plan denied your request. The Plan says inpatient care is no longer necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 continued inpatient mental health care. 
Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found 
the records do not indicate that the enrollees psychiatric symptoms cannot be managed on a less restrictive 
basis. The enrollee has chronic symptoms, and as of the last covered day, did not express any active suicidal 
ideation or intent, or any intent to harm herself or others.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) services provided on 
February 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an MRI. You say that this was medically necessary. The Plan denied your 
request. The Plan says this 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 magnetic resonance imaging (MRI) services 
provided on February 27, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressing provided on December 7, 2022. 
 
You asked the Plan to pay for the wound dressing. 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 valid physician order for the supplies provided in this case. 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 the wound dressing provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network pair of diabetic shoes and 
inserts 
 
You asked the Plan to waive the copayment for an in-network pair of diabetic shoes and inserts. You say that 
you changed Plans, thinking this new one was better and covered more. It does not, I should not have to pay 
this large payment. 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. Your 
contract with the Plan says that there is a $600 deductible which applies to durable medical equipment (DME) 
and related supplies.  
 
The item or service you asked the Plan to waive the copayment for falls within the durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $600 deductible which applies to durable medical equipment (DME) and related 
supplies.  
 This cost sharing is a contractual obligation that had not been met at the time an in-network pair of diabetic 
shoes and inserts was received on January 4, 2023. Therefore, we decided that the Plan does not have to waive 
the copayment for an in-network pair of diabetic shoes and inserts
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28755 billed for date of service December 5, 
2022.  
 You asked the Plan to pay for procedure code 28755. You say that the claim should be paid. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 28755 is 1. The MAI value for this code is 2. You billed two (2) units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 28755 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 28755 billed for date of service December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee has a known history of atrial fibrillation. 
A holter or MCT will not be beneficial for continued management for her atrial fibrillation. In her past, she has 
had an unsuccessful cardioversion.  The Plan denied your request. The Plan says an implantable loop recorder 
is only needed for enrollees with stroke of unknown cause or fainting spells of unknown cause. The enrollee 
does not meet this criterion. 
 
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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of atrial fibrillation. There is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ICM. In summary, 
there is insufficient documentation to support the medical necessity for insertion of an ICM in this enrollee's 
clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).