Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that you are requesting reconsideration based 
on medical necessity. The Plan denied your request. The Plan says your request does not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. Although the enrollee is beneath their previous functional status, the 
skilled therapy goals of minimum assistance are listed as long term goals thus, daily skilled therapy goals have 
been achieved. The clinical documentation does not support the medical necessity of continued daily skilled 
services on an inpatient basis in a skilled nursing 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the $200 eyewear allowance for the frames (V2020) and progressive lens 
(V2781) purchased on August 10, 2023. 
 
You asked the Plan to pay the $200 eyewear allowance for the frames and progressive lens. You say that this 
claim should qualify for the $200 annual benefit for prescription glasses. The Plan denied your request. The 
Plan says that at the time this eyewear was purchased, the provider was running a sales promotion of 50% off 
eyeglass lenses. The Plan also says that no additional reimbursement can be made for the eyeglasses because 
the amount you paid under the promotional offer ($627.50) was less than your contractual cost-sharing under 
the supplemental benefit ($885.00). 
 
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 a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the retail price for this eyewear was $627.50, 
because that is the price the retailer sold it at. There are no limitations listed in the 2023 Evidence of Coverage 
showing if the eyewear was on sale, the $200 allowance would not apply. You reasonably believed that your 
$200 eyewear allowance would be applied toward this purchase. Based on this information, we decided that the 
Plan's rules for coverage of the frames and progressive lens have been met. Therefore, we decided that the Plan 
has to pay the $200 eyewear allowance for the frames (V2020) and progressive lens (V2781) purchased on 
August 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist visit provided on October 04, 
2023. 
 
You asked the Plan to waive the coinsurance for a specialist visit. You say that you were never at this office. 
They are not being truthful with this billing. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 20% coinsurance for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $32.05 ($197.35 x 20% = 
$39.47), which is less than the full 20%. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a specialist visit provided on October 04, 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 the IRF services are medically necessary. The Plan 
denied your request. The Plan says the requested services are not reasonable and necessary.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service March 22, 
2023.  
 
You asked the Plan to pay for procedure code 99233. You say that the claim is billed correctly and 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 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 99233 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service March 22, 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 LTACH services. You say that the enrollee needs LTACH services and 
would be at risk for readmission to the acute care hospital if discharged to a lower level of care. The Plan 
denied your request. The Plan says the enrollee is currently unstable for transfer to an LTACH. 
 
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 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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. 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 he is not currently receiving but that would be available at the LTACH facility. The elements of 
coverage rules are not satisfied. The requested services cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of hemodynamic monitor. 
 
You asked the Plan to pre-approve an implantation of hemodynamic monitor. You say that you have spent over 
nine years in the hospital for life threatening issues and do not wish to subject yourself to that again. The Plan 
denied your request. The Plan says an implantation of hemodynamic monitor is considered investigational.  
 
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 implantation of hemodynamic 
monitor. Our reviewer says that an implantation of hemodynamic monitor is considered investigational. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the 
CardioMEMS system would not be considered medically appropriate and necessary in your 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 implantation of hemodynamic monitor. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantation of hemodynamic monitor.
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 the enrollee meets all conditions for 
approval of admission to the LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. 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. Given there are offered alternatives, LTACH is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional one-way, non-emergency trips. 
 
You asked the Plan pre-approve one-way, non-emergency trips. The Plan denied your request. The Plan says 
the services requested are beyond the number of 26 trips that are covered in your 2024 transportation 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 a maximum of 26 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have pre-approve additional one-way, non-emergency trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of an implant body: endosteal implant 
for tooth number 4 (D6010) and the extraction, of an erupted tooth requiring removal of bone and/or sectioning 
of tooth (D7210) provided on September 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service September 13, 2023. 
Specifically, the Plans contract states that there is a $2,000 combined allowance for supplemental preventive 
and comprehensive dental services every year. The Plan previously issued payments in the total amount of  
$2,000 ($53 + $274 + $1,673) for dental services provided in the 2023 calendar year. Therefore, you have 
exhausted the allowable benefit for the services provided in this case. Therefore, we decided that the Plan does 
not have to pay for the surgical placement of an implant body: endosteal implant for tooth number 4 (D6010) 
and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided 
on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the knee orthosis provided on September 
15, 2023. 
 
You asked the Plan to reduce the coinsurance for the knee orthosis. You say that the cost share is too high. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee orthosis. This item/service falls within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $108.82 ($544.12 allowed amount x 20% = 
$108.82). Therefore, we decided that the Plan does not have to reduce the coinsurance for the knee orthosis 
provided on September 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you do not 
feel you should owe $165 for the denied non-transport service. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
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 August 30, 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 provided on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter (99239) provided on July 4, 2023. 
 
You asked the Plan to pay for a hospital discharge day. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says code 99239 remains 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. 
 
 
 
 
 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 a hospital discharge day. Our reviewer says that the service 
does not meet criteria for payment on this claim. Our reviewer found the medical record includes a discharge 
summary report for date of service July 4, 2023, at 6:37 AM, however an ending time, or total time spent 
performing procedure was not found in the documentation. Code 99239 represents a "timed" procedure, which 
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 a hospital discharge day have not been met. Therefore, we decided that the Plan 
does not have to pay for a hospital inpatient or observation discharge day management; more than 30 minutes 
on the date of the encounter (99239) provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the benralizumab injection and the injection 
administration provided from June 22, 2023, to August 17, 2023. 
 
You asked the Plan to waive the cost share for the injection services. You say that you were not told of the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan clearly says that you must pay 
a $35 copayment for specialist provider and professional services. You have been asked to pay $1,002.69, which is 20% coinsurance of the allowed amount for the injection 
provided on June 22, 2023 ($5,013.45 allowed amount x 20% = $1,002.69). You have been asked to pay 
$1,025.55, which is 20% coinsurance of the allowed amount for each injection provided on July 20, 2023, and 
August 17, 2023 ($5,127.75 allowed amount x 20% = $1,025.55). These services fall within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  
 
You have also been asked to pay $25.02, which is less than the standard copayment for each injection 
administration provided on June 22, 2023, July 20, 2023, and August 17, 2023. These services fall within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the benralizumab injection and the injection administration provided from June 22, 
2023, to August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of the collection of venous blood described 
by code G0471-59 billed for date of service May 30, 2023. 
 
You asked the Plan to pay for G0471-59. You say that G0471-59 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says G0471-59 is denied because it is 
not supported in the documentation. 
 
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 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 G0471-59. Our reviewer says that G0471-59 is not supported 
in the documentation. Our reviewer found the record submitted consists of lab results. There is no evidence of 
an additional venipuncture or catheterization. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0471-59 have not been met. Therefore, we decided that the Plan does not have 
to pay for an additional unit of the collection of venous blood described by code G0471-59 billed for date of 
service May 30, 2023.