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

 
We decided that the Plan does not have to pay for Ophthalmological services, medical examination and 
evaluation (92014) and refraction services (92015) provided December 13, 2019. 
 
You asked the Plan to pay for the ophthalmology examination and refraction services. You say that you are 
requesting that this bill be paid in full or adjusted. The Plan denied your request. The Plan says these services 
are not covered under the plan benefits. 
 
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 an eye exam and 1 pair of eyeglasses or contact lenses is 
covered for people after cataract surgery. 
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. an eye exam and 1 pair of eyeglasses or contact lenses is covered for 
people after cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the 
ophthalmology examination and refraction services have not been met. Therefore, we decided that the Plan 
does not have to pay for Ophthalmological services, medical examination and evaluation (92014) and 
refraction services (92015) provided December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 18, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from October 30, 
2018 to December 18, 2018. 
 
You asked the Plan to pay for home infusion therapy. You say that this service has been paid in the past. The 
Plan denied your request. The Plan says this code is not valid for Medicare. 
 
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 CPT code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from 
October 30, 2018 to December 18, 2018.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services (A0430) provided on June 21, 
2019. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not emergent. There were network providers 
available. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 air ambulance services (A0430) provided on June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 20, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on April 10, 2019 and 
October 16, 2019. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you understand periodontal 
maintenance is not covered under your plan. You also say that in 2019 you received and paid for multiple 
dental exams, cleanings, and x-rays that you would like to be reimbursed for. The Plan denied your request. 
The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 the 
periodontal maintenance provided on April 10, 2019 and October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January
29, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were told that you would
not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and
you are being charged the correct amount.
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 $325
copayment for ambulance services.
You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the
ambulance services 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 copayment for ambulance services
provided on January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on January 30, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this should be covered because it was 
post-op. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $35 
copayment for outpatient diagnostic tests/in-network/x-rays/specialist's office.  
 
You have been asked to pay a $35 copayment for an x-ray provided in a specialist?s office. Post-op services are 
still subject to their own copayment; therefore, the correct copayment has been applied. An x-ray falls within 
the outpatient diagnostic tests/in-network/x-rays/specialist's office 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 copayment for an x-ray provided by a participating provider on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing services provided to the enrollee on September 
10, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical 
records (signed by the ordering physician) for the billed test 
 
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 CPT codes 87086, 87088 and 87186 are not supported in the medical record. Specifically, the case 
file does not contain a valid physician order for these services. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing services provided to the enrollee on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 9,
2020 to February 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically
appropriate. The Plan denied your request. The Plan says the denial of payment for inpatient level of care is
correct, because the records do not support an inpatient stay and observation level of care was appropriate for
this admission.
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 the record does not show that at the time of inpatient admission the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency
department and/or observation care) would span at least 2 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 from February 9, 2020 to February 10,
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient lab work provided by a 
participating hospital on April 21, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient lab work. You say that your doctor sent you there to 
get blood work. You say that you have never been charged $40 before. The Plan denied your request. The Plan 
says the correct copayment has been applied. 
 
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 $40 
copayment for outpatient diagnostic tests/in-network/laboratory test/outpatient hospital facility.  
 
You have been asked to pay a $40 copayment for outpatient lab work. The correct copayment has been applied 
to the services that were provided at an outpatient hospital facility. Outpatient lab work falls within the 
outpatient diagnostic tests/in-network/laboratory test/outpatient hospital facility 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 coinsurance for outpatient lab work provided by a participating hospital on April 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided from September 5, 2019 to 
February 20, 2020. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare 
program as of June 30, 2019. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the physician services provided from September 5, 2019 to February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on October 8, 2019. 
 
You asked the Plan to pay for the services. You say that the in-home medical evaluation was completed by a 
nurse practitioner. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
enrollee was seen in their home on October 8, 2019 for visit #6 of a licensed vocational nurse (LVN) care visit. 
According to Medicare, home services codes 99341-99350 are paid when they are billed to report evaluation 
and management services provided in a private residence. A home visit cannot be billed by a physician unless 
the physician (or advanced practitioner) was actually present in the beneficiary's home. Code 99350 is not 
supported by the medical records. Specifically, the medical records show the submitted services were 
performed by an LVN. The appeal submission states the services were rendered by a nurse practitioner, 
however, medical records document a LVN. The medical record is electronically signed by the LVN, and the 
non-participating physician who is billing the services signs the medical record via electronic DocuSign. The 
billed code does not appropriately reflect the services provided by the LVN, as such, Medicare rules for 
coverage have not been met. Therefore, the appealed 99350 performed by an LVN remains denied as not 
performed. Therefore, we decided that the Plan does not have to pay for home visit for the evaluation and 
management of an established patient (CPT Code 99350) provided to the enrollee on October 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health evaluation rendered on January 
16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the outpatient mental health evaluation rendered on January 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
January 1, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that all the tests were 
unnecessary because you were tested for everything you could think of. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the emergency room services on January 1, 2020. You are asked to 
pay a $90 copayment for the emergency room visit. Your EOC states that enrollees must pay a $90 copayment 
for each covered emergency room visit. 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 
emergency room services provided on January 1, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on February 24, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services 
were not billed with the appropriate modifier. 
 
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 Novitas Fact Sheet says that modifier 91 is used to report ?any repeat 
clinical diagnostic laboratory test being billed if: Specimen is collected more than once in a single day". In this 
case, modifier -59 appears appropriate to explain why the code was billed twice on the same date of service. 
The Plan has not provided documentation to substantiate its denial. Therefore, we decided that the Plan has to 
pay for the lab services provided on February 24, 2020.  
 
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: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay for eyewear. You say that you did not understand this process up front and want 
reimbursement of the $150 allowance that you are allowed. The Plan says that you did not understand this 
process up front and want reimbursement of the $150 allowance that you are allowed. 
 
We decided that the Plan has to pay an additional amount of $3 for eyewear provided on March 3, 2020.  
 
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 routine eyewear up to a $150 allowance for the year. 
 
We looked at the file and the Plan's rules. The Plan provided which shows they have already paid $147 of the 
$150 allowance for routine eyewear; however, it does not show that the full $150 allowance had been paid at 
the time this claim was processed. Therefore, your routine eyewear benefit was not exhausted at the time this 
claim was processed. Based on this information, we decided that the Plan must pay for this claim in the amount 
of $3, because this amount meets the $150 total allowance for routine eyewear in 2020. 
 
We also decided that the Plan does not have to pay the remaining requested amount for routine eyewear 
provided on March 3, 2020. 
 
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 routine eyewear up to a $150 allowance for the year. 
 
We looked at the file and the Plan's rules. After the Plan has complied with the decision to pay an additional $3, 
your $150 routine eyewear benefit for 2020 will be exhausted. Therefore, you are responsible for payment of 
any amount beyond this. Therefore, we decided that the Plan does not have to pay the full requested amount for 
eyewear provided on March 3, 2020. 
 
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.