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

 
We decided that the Plan does not have to pay for the audiometry for hearing aid evaluation (S0618), digital 
hearing aid (V5259), conformity evaluation (V5020), and hearing aid assessment (V5010) provided on August 
24, 2020. 
 
You asked the Plan to pay for the audiometry for hearing aid evaluation, digital hearing aid, conformity 
evaluation, and hearing aid assessment. You say that the treating provider told you they did not submit a claim 
because your plan was not going to pay. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the audiometry for hearing aid evaluation, digital hearing aid, conformity evaluation, and hearing aid 
assessment may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of 
items and services. Therefore, we decided that the Plan does not have to pay for the audiometry for hearing aid 
evaluation (S0618), digital hearing aid (V5259), conformity evaluation (V5020), and hearing aid assessment 
(V5010) provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply, accessory and/or service component 
(V2797) and vision items or services (V2799) provided on January 24, 2022. 
 
You asked the Plan to pay for the vision supply, accessory and/or service component and vision items or 
services. You say that there is no reason for this claim to be denied. The Plan denied your request. The Plan 
says your maximum benefit has been exhausted for the vision supply, accessory and/or service component. The 
Plan also says that protection plans are 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 up to $250 for eyeglasses every 12 months. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you purchased two pairs of glasses on January 
24, 2022, which the Plan issued the full $250 allowance for. Protection plans are not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the vision supply, accessory and/or service 
component and vision items or services have not been met. Therefore, we decided that the Plan does not have 
to pay for the vision supply, accessory and/or service component (V2797) and vision items or services (V2799) 
provided on January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has anemia in chronic kidney disease. The documentation does not support that the enrollee 
has tried and failed Retacrit or Procrit. The documentation does not support that Retacrit or Procrit would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99217) provided on January 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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, the CPT Code Manual definition of code 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])". 
 
 
 
 We asked our coder 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 the services. Our reviewer says that the use of code 99217 is 
not supported by the records provided. Our reviewer found that the medical records submitted describe "patient 
received emergency department (ED) services on December 31, 2021 at 12:59. A hospitalist provided 
evaluation and management services on December 31, 2021 at 7:07 AM, and Discharge summary provided on 
January 2, 2022." In this case, the documentation does not indicate observation status dates of service, and time 
of services provided on December 31, 2021, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 the services (99217) provided on January 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), therapeutic activities 
(97530), and the office visit (99212) provided on March 15, 2022. Additionally, we decided that the Plan does 
not have to waive the copayment for the chiropractic manipulative treatment (98941) provided on March 15, 
2022. 
 
You asked the Plan to pay for these services. You also asked the Plan to waive the copayment for the 
chiropractic manipulative treatment provided. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not covered under 
your contractual policy or by Medicare. Additionally, the copayment has been applied correctly to the 
chiropractic treatment provided. 
 
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 services at issue are not manual manipulation of the spine. Additionally, you have 
been asked to pay a $20 copayment for the chiropractic manipulative treatment provided. The Plan contract 
states that enrollees must pay a $20 copayment for each Medicare-covered chiropractic visit. Therefore, we 
decided that the Plan does not have to pay for the therapeutic exercises (97110), therapeutic activities (97530), 
and the office visit (99212) provided on March 15, 2022. Additionally, the Plan does not have to waive the 
copayment for the chiropractic manipulative treatment (98941) provided on March 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 13, 
2022, to January 30, 2022. 
 
You asked the Plan to pay for the home health care. You say that the enrollee was not enrolled in hospice on 
the dates of service in this case. The Plan denied your request. The Plan says the enrollees 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 providers 
responsibility to verify the enrollees 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. 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 January 3, 2022. 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 home health care 
services provided from January 13, 2022, to January 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusion on January 14, 2022. 
 
You asked the Plan to waive the coinsurance for infusion. You say that you cannot afford it. The Plan denied 
your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs. These drugs are covered 
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. 
Covered drugs include drugs that usually arent self-administered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed 
in the amount of $51,308 and the allowed amount is $10,792.01. The Plan paid $8,700.01. $10,792.01 - 
$8,700.01 = $2,092. Therefore, results in the total cost-sharing amount of $2,092. 
 
 
 You have been asked to pay a 20% coinsurance for infusion. Infusions fall within the Medicare Part B 
prescription drugs 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 infusion on January 
14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venography and testing services to be received from an 
out-of-network provider. 
 You asked the Plan to pre-approve out-of-network care. You say that these services are medically necessary 
and are covered by the Plan, and you have been following up with the enrollee for more than six months and 
have a set care plan. The Plan denied your request. The Plan says out-of-network care is only covered in certain 
limited circumstances. The requested services are not urgent or emergent, and there are network providers 
available who can perform these services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 out-of-network care. Our reviewer says 
that out-of-network care is not medically necessary in this case. Our physician reviewer found the record 
indicates that the enrollee has had issues with venous stasis and bilateral lower extremity edema for the past six 
months. There is no specific indication for out of area services. The Plan has provided information for multiple 
in-network providers who can perform these services, and it is safe at this time for the enrollee to transfer 
treatment to an in-network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of out-of-network care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve venography and testing services to be received from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in addition to single gene testing, Medicare will 
also deny panels of tests that include the FANCC gene. 
 
We looked at the file and Medicare rules. The panel testing included the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (0037U) provided January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visit provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you should only be charged $35 
copayment not $50. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for each Medicare covered podiatry visit.  
 
You have been asked to pay $50 copayment for office visit. Office visit fall within the Podiatry 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 podiatry office visit provided on 
April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on April 25, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was a routine eye exam and should 
be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $45 
copayment for each office visit to other providers.  
 
 
 
 
 
 
 
 
 You have been asked to pay $45 copayment for eye exam. Eye exams fall within the Vision Care 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 eye exam provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from March 18, 2022, to April 
1, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the enrollee is entitled to all Medicare 
approved services. The Plan denied your request. The Plan says services from non-participating providers are 
not covered unless they are authorized/approved before the services are provided. 
 
  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 chiropractic services provided from March 18, 
2022, to April 1, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan of the thoracic 
spine (72146) provided on February 23, 2022. 
 
You asked the Plan to pay for a spinal MRI scan. You say that the claim at issue is not a duplicate. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 30, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for a spinal MRI scan have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan of the 
thoracic spine (72146) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
March 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service March 24, 2021. The Plan 
contract covers one panoramic radiographic image every three plan years. You previously received this service 
on March 24, 2021; which has been paid for by the Plan. Therefore, the benefit for this service has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image 
(D0330) provided on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (D7140 x23) 
reconstruction of mandible or maxilla, endosteal implant (21249 x2) unlisted dental procedure (41899) 
Anesthesia for intraoral procedures, including biopsy (00170) provided March 23, 2022. 
 You asked the Plan to pay for the removal of teeth in preparation for dental implants,. You say that you are 
requesting a review and possible reconsideration of a payment on the claim. The Plan denied your request. The 
Plan says this service is not covered under the Plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The health Plan contract 
specifically says that the Plan will cover the extraction of the teeth to prepare the jaw for radiation treatments of 
neoplastic cancer disease. 
 
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 
extraction, erupted tooth or exposed root (D7140 x23) reconstruction of mandible or maxilla, endosteal implant 
(21249 x2) unlisted dental procedure (41899) Anesthesia for intraoral procedures, including biopsy (00170) 
provided March 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 27, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you thought the copayment 
would be waived. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $300 
copayment for each one-way Medicare covered trip.  
 
 
 
 
 
 
 You have been asked to pay $300 copayment for ambulance transport. Ambulance transport falls 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 transport 
provided on November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on February 8, 2022.