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

We decided that the Plan does not have to provide additional payment for the lenses, frames and anti-reflective 
coating provided on July 7, 2020. 
 
You asked the Plan to provide additional payment for the lenses, frames and anti-reflective coating. You say 
that you would like Plan to pay for these services. The Plan denied your request. The Plan says that the claim 
has been paid correctly. 
 
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 1 pair of lenses and frames every 2 years. Anti-reflective coating is not covered. 

We looked at the file and the Plan's rules. The file indicates the Plan has paid for one pair of lenses and frames 
for this date of service. The Plan rules also indicate that anti-reflective coating is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the lenses, frames and anti-reflective 
coating have not been met. Therefore, we decided that the Plan does not have to provide additional payment for 
the lenses, frames and anti-reflective coating provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 24, 2019 
under codes 88305, 88313, and 88312. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing guidelines state that all claims submitted for lab tests are subject to 
CLIA edits. CMS identifies the new HCPCS codes in the 80000 series that are excluded from CLIA edits by 
providing an updated listing of these tests on an annual basis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, this claim cannot be paid as billed due to issues with the codes reported and CLIA edits. Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on October 24, 2019 under codes 88305, 88313, and 88312.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor for the 
enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have type II diabetes, for which she uses both oral medication and insulin.  While 
the insulin appears to be administered in accordance to an ISS, how many times a day this is done is not noted.  
The enrollee is ordered to use a CGM four times a day to check her blood glucose. How often this is actually 
done is not documented (no log, no provider review of log). As the documentation does not actually show that 
the enrollee tests her blood glucose multiple times a day and uses these results to self-adjust self-administered 
insulin doses multiple times a day, the use of a CGM is not shown to be medically necessary and reasonable. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor for the enrollee.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer may be considered when treatment has completed and the weaning status is more 
clear. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services (97598, 97597) provided on June 
23, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that the medical records support the necessity 
for services rendered. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 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 wound care services (97598, 97597) provided 
on June 23, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on July 
20, 2020. 
 
You asked the Plan to pay for the local anesthesia. You say that you were billed $273 immediately for the 
services that you received. You say that after you received an explanation of dental reimbursements you called 
your dental office. You say that you were told you owed an additional $175 for the services you received. You 
also say that this is completely different from the Plan's explanation. The Plan denied your request. The Plan 
says local anesthesia in conjunction with operative or surgical procedure is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
prefabricated post and core in addition to a crown (D2954) and local anesthesia in conjunction with operative 
or surgical procedures (D9215) provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for swim club membership, non-covered item or service 
(A9270) purchased January 30, 2020. 
 
You asked the Plan to pay for the swim club membership. You say that you are going to a program where you 
pay a monthly fee. There are dedicated lanes. They have done a significant amount more for Covid protection 
than the gym has been. The Plan denied your request. The Plan says membership to a pool is not covered under 
the plan benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only the membership is to a qualified health club or fitness facility. 
 
The Plan's rules for coverage of gym benefits have not been met because a swim club membership is not 
covered under the Wellness allowance. This benefit does not cover membership fees you pay to non-qualified 
health clubs or fitness facilities, including but not limited to, martial arts centers, gymnastics facilities, country 
clubs, sports clubs and social clubs; and for sports activities such as golf and tennis.. Therefore, we decided that 
the Plan does not have to pay for swim club membership, non-covered item or service (A9270) purchased 
January 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy (52000, J7030) provided on June 19, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON cystourethroscopy. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was 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 has network providers 
available who can provide 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 cystourethroscopy (52000, J7030) provided on 
June 19, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on  March 3, 
2020. 
 
You asked the Plan to pay for train of four testing. You say that this should be covered. The Plan denied your 
request. The Plan says this is not separately payable. 
 
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 
95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not 
a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. 
Based on this information, we decided that Medicare rules for coverage of train of four testing have not been 
met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on 
March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve center mount foot platform, calf pad assy, foot plate 
with extension (CPT Code K0108 X3) and power wheelchair accessory, electronic connection between 
wheelchair controller and one power seating system motor, including all related electronics, indicator feature, 
mechanical function selection switch, and fixed mounting hardware (CPT Code E2310). 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The calf pads are already included 
with the approved wheelchair. These cannot be requested separately. There is a request for foot plates. The 
codes used do not match the items requested. These cannot be covered as requested. A request for foot plates 
that meet your needs can be reviewed if submitted. Approval is subject to correct coding by your wheelchair 
provider. The upgraded electronics (electronic connector to 1 power option) are not medically necessary. They 
cannot be covered. They are necessary when there is a medical need to control power options though the 
joystick. The notes do not show a medical need to control the power option through the joystick. The power 
option can be controlled using its own switch. This switch can be made any size without asking for a separate 
request. It can be made from any material without asking for a separate request. All of this can be done without 
the need to use the joystick to control the power feature. Therefore, we decided that the Plan does not have to 
pre-approve center mount foot platform, calf pad assy, foot plate with extension (CPT Code K0108 X3) and 
power wheelchair accessory, electronic connection between wheelchair controller and one power seating 
system motor, including all related electronics, indicator feature, mechanical function selection switch, and 
fixed mounting hardware (CPT Code E2310).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 26, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services 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. 
 
We find that the home health services are not supported in the medical record. Specifically, the HHRG code on 
the claim indicates there were Non-Routine Supplies (NRS) provided, but none were submitted on the claim. 
Additionally, the submitted HIPPS code is invalid. Based on this information, we decided that Medicare rules 
for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have 
to pay for home health services provided February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 10, 2020. 
 
You asked the Plan to pay for out of network providers. You say that you prefer not to change physicians. The 
Plan denied your request. The Plan says this physician is not in your Plans network of providers. 
 
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 has network providers available 
who can provide 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 out of network physician services provided on June 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 26, 2020 to April 
26, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not submitted correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the home health services are not supported in the record. Specifically, the claim included an 
invalid HIPPS code for the services billed. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided February 26, 2020 to April 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services were medically necessary. The Plan denied 
your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-
of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 office visit (99214) provided on February 25, 
2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on March 11, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you were advised to bill the enrollee's 
Medicare or Medical insurance company. You also say that you were advised the enrollee was not enrolled in 
hospice until after she was transported home. The Plan denied your request. The Plan says the enrollee's claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
provider's responsibility to verify the member's coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the transportation services provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) for tooth # 30 provided on June 25, 2020. 
 
You asked the Plan to pay for the dental service. You say that you feel the plan should have paid a lot more for 
the crown that you received. You say that your dental plan submitted an electronic payment which your 
provider dos not accept. You also say that you will be charged this amount too if it is not resolved. The Plan 
denied your request. The Plan says a decision could not be made within the allowed time frame. 
 
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 and crowns are listed as a covered 
service, there is a $100 deductible for covered dental services that must be met before the Plan will begin to 
pay for dental services. This is a contractual obligation you agreed to when you enrolled in the Plan's dental 
coverage. Additionally, the provider in this case is not a network provider. The Evidence of Coverage states 
that services you receive out of network may cost more. Out of network providers are able charge the 
difference between the billed amount and the amount the Plan will pay. Therefore, we decided that the Plan 
does not have to pay for the crown (D2750) for tooth # 30 provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker purchased on August 10, 2020. 
 
You asked the Plan to pay for the walker. You say that you were told that you would be reimbursed for this 
purchase. The Plan denied your request. The Plan says that you will pay the full cost of services provided by 
providers excluded from the Medicare program. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the walker purchased on August 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on August 3, 2020. 
 
You asked the Plan to pay for the surgical pathology 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 
surgical pathology 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 surgical pathology services provided on August 3, 
2020.