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

 
We decided that the Plan does not have to pay for lab services provided on October 19, 2020. 
 
You asked the Plan to pay for the lab services. You say that this claim denied in error because the medical 
records support this level of service. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) closure of lacrimal 
punctum; by plug, each (68761) scanning computerized ophthalmic diagnostic imaging (92134) provided on 
March 14, 2022 to March 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial for the services. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99214) closure of 
lacrimal punctum; by plug, each (68761) scanning computerized ophthalmic diagnostic imaging (92134) 
provided on March 14, 2022 to March 15, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 18, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you passed out while at a concert. You say 
that your husband arrived at the same time as the ambulance. You also say that you chose not to go to the 
hospital to save your plan money. The Plan denied your request. The Plan says since no transport was provided, 
there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82306, 82607, and 82746) provided 
on April 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (82306, 82607, and 82746) provided on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided on April 8, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that regardless of whether the clinic or provider 
verified network status, the provider still chose you to send the test to your lab in effort to devise the treatment 
plan they felt was best for the enrollee. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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. The PCR testing is also considered unproven and not medically necessary. 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 Urine PCR panel testing provided on April 8, 2022 by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile imaging services provided on February 7, 2022 
by an out-of-network (OON) provider. 
 
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. 
 
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 mobile imaging services provided on February 
7, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit and biopsy services provided from 
July 2, 2021, to July 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physician office visit and biopsy services. You say that you were referred to the 
OON provider by the Plan. The Plan denied your request. The Plan says rules for payment for OON care have 
not been met. 
 
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 a physician office visit and biopsy services 
provided from July 2, 2021, to July 19, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 5, 2022. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says you billed with an incorrect Place of Service (POS) code 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate Place of 
Service (POS) code on the claim.  In this case, you billed POS code 11. However, the records indicate that the 
services were performed in a hospital setting, not in an office setting.  As a result, POS 19, 21, or 22 should 
have been used on the claim, depending on the patient's status. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the One Touch Verio test strips 
 
You asked the Plan to pay for the One Touch Verio test strips. You say that you paid for the test strips because 
you needed more because you are testing your blood sugar 7-8 times a day. The Plan denied your request. The 
Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the One Touch Verio test strips have not been met. 
Therefore, we decided that the Plan does not have to pay for the One Touch Verio test strips
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided March 25, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you feel the hearing aids should be paid. The Plan 
denied your request. The Plan says the provider is not part of the Plan's hearing network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided through the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. In this case the provider is not part of the Plans hearing aid network 
and were not pre-approved. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
(V5261) provided March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 14, 
2022. 
 
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 Current Procedural Terminology (CPT) code 83789-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided to the enrollee on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298, V5299, S9999) provided March 21, 
2022. 
 
You asked the Plan to pay for the hearing aids. You say that this provider offers a superior product. The Plan 
denied your request. The Plan says hearing aids are not covered unless purchased through the Plan's hearing aid 
vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans hearing aid vendor. 
 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The hearing aids at issue were purchased out-of-network without 
prior approval. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298, V5299, 
S9999) provided March 21, 2022.
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 the medical record does not indicate that you require services that you are not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism correcting function of intraocular lens (V2787) 
provided August 18, 2021. 
 
You asked the Plan to pay for astigmatism correcting function of intraocular lens. You say that your claim is 
separate from your providers claim and you are only appealing the denial of the coverage for the toric lens and 
laser components of the surgery. The Plan denied your request. The Plan says this service is not a covered 
benefit.: Medicare covers cataract surgery and a conventional IOL only. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for astigmatism 
correcting function of intraocular lens (V2787) provided August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 8, 
2022 by an out-of-network (OON) provider. 
 
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. 
 
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 computed tomography (CT) scan provided on 
March 8, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the integumentary system on the 
extremities, anterior trunk, and perineum; not otherwise specified 
 
You asked the Plan to pay for the anesthesia services. You say that a separate authorization should not be 
required for anesthesia services. The Plan denied your request. The Plan says that an approved authorization 
exists, however either the service performed, the servicing provider or the number of visits billed do not match 
what was approved on the authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of anesthesia for procedures on the 
integumentary system on the extremities, anterior trunk, and perineum; not otherwise specified have been met. 
The Plan has not substantiated their reason to continue to deny payment. The case file did not contain the 
approved authorization, nor is there an explanation of benefits showing what services the Plan had paid on or 
that a payment has been made towards the services. Therefore, we decided that the Plan has to pay for 
anesthesia for procedures on the integumentary system on the extremities, anterior trunk, and perineum; not 
otherwise specified  
 
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 Dexcom system and associated supplies. 
 
You asked the Plan to pre-approve a Dexcom system and associated supplies. You say that the items 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom system and associated supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom system and associated supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac (SI) joint injection provided on February 15, 
2022 by an out-of-network (OON) provider. 
 
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. 
 
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 sacroiliac (SI) joint injection provided on 
February 15, 2022 by an out-of-network (OON) provider.