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

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that these transportation trips are for your 
dialysis treatments that are in a different county from where you live. You also say that your treatments are 3 
times a week and you will run out of rides before your treatment ends at the current location.  The Plan denied your request. The Plan says the records show that you have utilized 14 of the 30 rides 
available to you. Once the 30 rides are exhausted, there are no additional rides available to other healthcare 
related locations. 
 
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 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve an 
additional 20 transportation trips for you dialysis appointments. 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 to pre-approve 20 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the deluxe frames, and the bifocal lenses 
provided on May 20, 2023. 
 
You asked the Plan to pay for the frames, the deluxe frames, and the bifocal lenses. You say that you did not 
know that you had to go to an in-network provider. The Plan denied your request. The Plan says the provider 
was out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the frames, the deluxe frames, and the bifocal 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames, the deluxe 
frames, and the bifocal lenses provided on May 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212), nerve conduction studies (95913), 
and needle electromyography (95886) provided on December 8, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services were rendered as needed. You 
also say that records were provided to support medical necessity. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 office visit (99212), nerve conduction studies (95913), and 
needle electromyography (95886) provided on December 8, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95957 for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 95957. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 procedure code 95957 is an add-on code and has not been billed with an appropriate primary procedure code. 
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 95957 for date of service May 2, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Omega3 skin substitute. 
 
You asked the Plan to pre-approve Omega3 skin substitute. You say that this is Food & Drug Administration 
(FDA) indicated for multiple clinical applications. The Plan denied your request. The Plan says that the Keracis 
Omega 3 brand skin substitute is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Omega3 skin substitute. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical documentation supports that the enrollee is suffering with an open 
wound to the right foot status post soft tissue excision. The wound remains open despite conservative care 
including debridement, wound vacuum-assisted closure (VAC), and Prisma collagen application. The medical 
documentation also advises that the enrollee is at risk for infection due to a chronically open wound. Keracis 
Omega 3 is homologous to human skin substitute and is FDA-approved for application to partial and full 
thickness wounds, diabetic foot ulcerations, and venous ulcerations. Multiple studies demonstrate significant 
improvement in wound closure with this application. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Omega3 skin substitute have been met. Therefore, we decided that the Plan has 
to pre-approve Omega3 skin substitute.  
 
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 a group 2 standard power operated vehicle (scooter) 
(K0806). 
 
You asked the Plan to pre-approve the scooter. You say that you feel your current scooter is unsafe to move 
around in and you have to make sure you are attending your appointments. The Plan denied your request. The 
Plan says the requested new power operated vehicle (scooter) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV (such as code K0806) is 
provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 standard power operated vehicle (scooter) (K0806).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready to go home and live 
independently. You also say if the enrollee is sent home without the SNF stay, they may be a fall risk. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF services. 
 
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 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 that 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 SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee's inpatient stay is 
medically necessary after surgery. The Plan denied your request. The Plan says inpatient hospital care is not 
medically necessary. Should any issues arise during or after surgery to support acute inpatient level of care, 
reconsideration may be requested. 
 
 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found at the time of the surgery, it is not clear that the enrollee's necessary 
hospital care would span two midnights. Therefore, we do not believe the enrollee's admission is 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you are appealing this denial for extra 
transportation rides because your glaucoma has worsened and you don't drive. You also say that you  had 2 
surgeries this year and fear you are going blind. The Plan denied your request. The Plan says you have used 
your allowed transportation trips this year. 
 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 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
routine transportation trips for your appointments. 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 to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the LTACH level of 
care and is stable to transfer to the LTACH. You would like reconsideration based on the records submitted.  
The Plan denied your request. The Plan says the request for an LTACH admission does not meet medical 
necessity.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. 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 
services are 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photochromatic lenses (V2744), anti-reflective coating 
(V2750) and lens (V2782) provided on June 7, 2023. 
 
You asked the Plan to pay for photochromatic lenses (V2744), anti-reflective coating (V2750) and lens 
(V2782). You say that based on foregoing and what Medicare has indicated, your total out-of-pocket should 
not exceed $55. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eyeglasses are standard frames and lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that Medicare covers one pair of standard frames 
and lenses after each cataract surgery that includes insertion of an intraocular lens. The Plan rules also say that 
any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-
reflective coating). Based on this information, we decided that the Plan's rules for coverage of photochromatic 
lenses (V2744), anti-reflective coating (V2750) and lens (V2782) have not been met. Therefore, we decided 
that the Plan does not have to pay for photochromatic lenses (V2744), anti-reflective coating (V2750) and lens 
(V2782) provided on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services. 
 
You asked the Plan to pay for chiropractic services. You say that you feel this service should be covered. The 
Plan denied your request. The Plan says that their original decision to deny payment was correct. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 21, 2023, billed with 
codes 92611, 74230, 72040, 70100, 70310, 71045, and 74240. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid place of 
service.  
The Plan must follow Medicare rules. Medicare rules say that the POS code reflects the actual place where the 
beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is 
paid. 
 
We looked at the file and Medicare rules. The POS code 11 which was reported is not supported because the 
records clearly indicate that the services took place at a nursing home. There is no evidence that the services in 
dispute were performed in the office setting. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on March 21, 2023, billed with codes 92611, 74230, 72040, 70100, 
70310, 71045, and 74240.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided April 14, 
2023, to April 28, 2023. 
 You asked the Plan to pay for the SNF care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 14, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) care provided April 14, 2023, to April 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee has been cleared for discharge and does not require 
skilled care daily. The Plan says further rehabilitation services may be provided at home physical and 
occupational therapy through home health services. 
 
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 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression device with sequential 
calibrated gradient pressure (Koya Dayspring). 
 
You asked the Plan to pre-approve Koya Dayspring. You say that this has been proven effective for the 
enrollee's condition. The Plan denied your request. The Plan says the current literature does not consider 
Dayspring to be a standard medical treatment. 
 
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 Koya Dayspring. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found peer-reviewed medical literature does not document that use of Koya Dayspring 
device has been show in controlled studies in a Medicare-approved journal to result in long-term health benefits compared to standard pneumatic compression devices. The records do not document trial and failure or 
standard pneumatic compression devices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Koya Dayspring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-pneumatic compression device with sequential calibrated gradient pressure 
(Koya Dayspring).