Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external ocular photography and the entropion repair 
provided on February 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the external ocular photography and the entropion repair. You say that your local 
doctor could not see you for months. You say you were referred to a different doctor and were told they 
accepted your insurance. The Plan denied your request. The Plan says you were referred by an out-of-network 
provider and the rendering provider was out-of-network. 
 
 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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the external ocular photography and the entropion repair provided on 
February 8, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service 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 your benefit for the requested item or service was exhausted on date of service January 28, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 
1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intra-facet implants (0219T, 0222T). 
 
You asked the Plan to pre-approve the intra-facet implants. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intra-facet implants have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intra-facet implants (0219T, 0222T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0364), prophylaxis (D1110), and pulp 
vitality tests (D0460) provided on November 2, 2022. 
 
You asked the Plan to pay for cone beam CT, prophylaxis, and a pulp vitality test. 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 pay for cone 
beam CT (D0364), prophylaxis (D1110), and pulp vitality tests (D0460) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the progressive lens, the polycarbonate lens, the anti-reflective 
coating, and the ultraviolet (UV) lens provided on January 17, 2023. 
 
You asked the Plan to pay more for the progressive lens, the polycarbonate lens, the anti-reflective coating, and 
the ultraviolet (UV) lens. You say that your vision benefit should pay $400 towards covered services. The Plan 
denied your request. The Plan says that the claim processed correctly. 
 
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 submitted a blank Explanation of Benefits. This means we are unable to 
confirm the amount the Plan paid towards the services and if the benefit was applied correctly. Therefore, we 
decided that the Plan has to pay more for the progressive lens, the polycarbonate lens, the anti-reflective 
coating, and the ultraviolet (UV) lens provided on January 17, 2023. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Contour Next test strips. 
 You asked the Plan to pre-approve the Contour Next test strips. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Contour Next test strips. Therefore, we decided that the Plan does not have to pre-approve Contour Next 
test strips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided from February15, 2022, to 
February 28, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care by an OON provider. You say that there are no in-network 
providers in your area, and you had to receive care at this facility. The Plan denied your request. The Plan says 
the 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 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 nursing facility care provided from February15, 
2022, to February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 76641.  
 
You asked the Plan to pay for testing services provided on January 23, 2023, billed with codes 76641, 77067, 
and 77063. You say that the claim was billed correctly and should be paid. The Plan says that the number of 
units billed exceeds the maximum allowed.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 77067 and 77063.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
76641. 
 
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value for the HCPCS/CPT code will be denied. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 76641 have not been met. In this case, the MUE for 
CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 
Specifically, you billed one line item of this code with the LT modifier and one line item of this code with the 
RT modifier instead of billing one line item with the bilateral modifier as is required. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 76641. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service October 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing was not billed with a single 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 panel testing billed for date of service October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria, and their ongoing 
rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan denied 
your request. The Plan says criteria for admission to the IRF setting have not been 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the testing remains unproven. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records show that the Cxbladder Detect helps the early detection of 
canter. The records do not show that the results of testing will improve the enrollees outcome. Medicare does 
not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
testing billed for date of service December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
March 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was underpaid. The Plan denied your 
request. The Plan says the documentation does not support the billing.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the HIPPS code 2HC11 is not supported in the medical record. The records do not show the 
enrollee had an inpatient stay prior to the start of home care. The records provided only show the enrollee was 
seen in the emergency room. 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 home health 
services provided from February 9, 2022, to March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tafluprost solution 0.0015%. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve tafluprost solution 
0.0015%.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 were independent and active before coming to 
the hospital and wish to return to being independent as quickly as possible. The Plan denied your request. The 
Plan says your records do not show that you have complex rehabilitation needs that require frequent evaluation 
by a rehabilitation doctor. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient has been approved for this 
ventilator in the past and other machines will not work for the patient. The Plan denied your request. The Plan 
says the patient does not meet criteria for a home ventilator. The patient is using this item exclusively in the 
average volume-assured pressure support (AVAPS) mode that can be provided by a bilevel positive airway 
pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
However, the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device 
with AVAPS and a back-up rate. The provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. The coverage rule requires: "There must be enough detailed information in 
the medical record to justify the treatment selected." The provided records in this case do not provide adequate 
detailed information to meet Medicare criteria for coverage.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OptiMesh device (20930). 
 
You asked the Plan to pre-approve the OptiMesh device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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 OptiMesh device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found there is insufficient high-quality evidence to support OptiMesh over standard bone 
allografting for this type of surgery (laminectomy/facetectomy/foraminotomy/spinal decompression) in terms 
of long-term outcomes. 
 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 OptiMesh device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the OptiMesh device (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that the enrollee has a limited range of motion. 
You also say that the walk-in bathtub will help to prevent falls and promote good hygiene. The Plan denied 
your request. The Plan says items for convenience are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.