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

 
We decided that the Plan has to pay $40 more for the eyewear. We decided that the Plan does not have to pay 
in full for the eyewear.  
 
  You asked the Plan to pay more for the deluxe frame (V2025) and progressive lens (V2781) provided on 
March 8, 2023. You say that the Explanation of Benefits you received does not match the charges you paid for 
at the location. You also say that you would like for someone to look into this. The Plan says that this claim 
processed correctly. The Plan also says that they contacted the provider on May 18, 2023, and confirmed that 
you paid $125.00 on the date of service. 
 
We decided that the Plan has to pay $40 more for the eyewear.  
 
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 offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan only paid $60 toward this 
purchase. Write-offs and disallowed amounts are not benefits that are actually paid by the Plan. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have been met. The remaining 
balance of your eyewear benefit is $40. Therefore, we decided that the Plan has to pay $40 more for the 
eyewear. 
 
We also decided that the Plan does not have to pay in full for the eyewear. 
 
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 offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. We decided that the Plan must pay the remaining $40 of your 
eyewear benefit. Once this amount is paid, your eyewear allowance will be exhausted. 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 in full for the eyewear. 
 
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 you need aggressive rehab before returning home.  
The Plan denied your request. The Plan says your records do not show that you have a complex rehabilitation 
needs.  
 
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 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: 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. The Plan denied your request. The Plan says the enrollee's records 
do not show 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 the enrollee's 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the testing is not a covered service. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met.  
 
The file shows that a Guardant Reveal test was provide. We looked at the file and Medicare rules. This test 
does not meet the requirements for the MolDX program and is not covered. Therefore, we decided that the Plan 
does not have to pay for the lab testing billed for date of service December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service January 21, 
2023.  
 
You asked the Plan to pay for procedure code 99222. You say that the payment should not be included in 
payments made to other providers. The Plan denied your request. The Plan says payment for code 99222 is 
bundled into payment for code 99223. 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, we have confirmed that code 99222 is a column II code to column I code 99223 with a modifier 
indicator of 0. Both services were provided by the same provider on the same date of service. The column II 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 billed for date of service 
January 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 18, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the provider is 
not an eligible provider. 
 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. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on February 18, 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 you need acute rehab and therapy. The Plan denied 
your request. The Plan says that you do not meet the criteria for admission to an IRF.  
 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 8, 2022, to 
October 9, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this level of care was necessary to 
mitigate any potential risks. The Plan denied your request. The Plan says these services were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found it was reported that the enrollee was in the operating room for four hours, however, 
vitals were stable post-operatively, she was tolerating oral, and was able to ambulate the next day with pain 
controlled. It was not expected that the enrollee would require hospitalization that would likely cross two 
midnights due to her stability and simple treatment requirements.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 8, 2022, to October 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due 
to worsening heart failure. The Plan denied your request. The Plan says the clinical value and effectiveness of 
CardioMEMS have not been demonstrated. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-sterile gloves (A4927).  
 
You asked the Plan to pay for incontinence supplies. You say that the items should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for non-sterile gloves (A4927).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the virtual care visit provided on January 5, 2023, to March 
2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the virtual care visit. You say that the service should be covered. The Plan denied 
your request. The Plan says the service is not covered when obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that that plans may choose the networks of providers available to enrollees. 
 
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 the virtual care visit provided on January 5, 2023, 
to March 2, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 27, 2023, to January 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not told there 
would be a copayment for this stay. 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 a $300 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for any additional days of the same in-network inpatient 
hospital stay.  
 
You have been asked to pay a $300 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
two or for the day you were discharged. You have been asked to pay a total of $600 ($300 copayment per day x 
2 days = $600). 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 copayment for the inpatient hospital stay provided from 
January 27, 2023, to January 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear (codes V2781, V2783, V2781, V2799, 
V2020, V2702, V2299, V2783, and V2750) purchased on October 26, 2022. 
 
You asked the Plan to pay more for the eyewear. You say that you cannot see out of the glasses, and they do 
not fit you correctly. You also say that you tried to get your glasses fitted and lenses changed, but they refused, 
and you were not advised that deluxe lenses were not covered. The Plan denied your request. The Plan says the 
$300 maximum benefit was applied to this purchase. 
 
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 maximum plan allowance for supplemental eye wear of $300 every calendar year. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that this full $300 allowance was applied toward 
this purchase, and your supplemental eyewear allowance benefit has been exhausted. 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 more for the eyewear (codes V2781, V2783, V2781, V2799, V2020, 
V2702, V2299, V2783, and V2750) purchased on October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardioverter defibrillator. 
 
You asked the Plan to pre-approve an implantable cardioverter defibrillator. You say that an implantable 
cardioverter defibrillator is medically necessary. The Plan denied your request. The Plan says an implantable 
cardioverter defibrillator does not meet the Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that an implantable cardioverter defibrillator is covered 
when the criteria listed in the Medicare rules section of this decision 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 an implantable cardioverter 
defibrillator. Our reviewer says that the requested implantable cardioverter defibrillator is not considered 
medically necessary. Our physician reviewer found that the clinical documents do not show that the enrollee 
meets implant criteria for defibrillator insertion according to current guidelines. The echocardiographic ejection 
fraction in October 2021 was 40-45% and in April 2023 was 35-40%. As such, implantation of an automatic 
defibrillator would not be considered medically necessary in the management of this enrollee. 
 
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 implantable cardioverter defibrillator  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantable cardioverter defibrillator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 21, 2022, to 
July 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee had a pubic fracture, and 
an admission was medically necessary. The Plan denied your request. The Plan says an admission was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found based on the enrollee's simple care plan and stability, it was not expected that the 
patient would require hospital care that would likely cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided July 21, 2022, to July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care services provided on December 5, 
2022, by an OON provider.  
  
 
You asked the Plan to pay for the mental health care services. You say that services were provided in good 
faith. The Plan denied your request. The Plan says the services were 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 the mental health care services provided on 
December 5, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on February 08, 2023.