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

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), photochromatic tint 
(V2744), progressive lens (V2781), polycarbonate lens (V2784), and deluxe frames (V2025) provided on 
February 25, 2022 by a non-network provider. 
 
You asked the Plan to pay for the anti-reflective coating, photochromatic tint, progressive lens, polycarbonate 
lens, and deluxe frames. You say that you were denied coverage even though you can use an out-of-network 
provider through your policy. The Plan denied your request. The Plan says these services were rendered by a 
provider who is not in the Plan's network. The Plan also says that your benefit Plan does not cover this out-of-
network vision care service. 
 
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 they are provided by an approved vision care provider. 
 
 We looked at the file and the Plan's rules. The record shows that these services were provided by a non-
network provider. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective 
coating, photochromatic tint, progressive lens, polycarbonate lens, and deluxe frames have not been met. 
Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750), 
photochromatic tint (V2744), progressive lens (V2781), polycarbonate lens (V2784), and deluxe frames 
(V2025) provided on February 25, 2022 by a non-network provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, greater occipital nerve (64405), the injection, 
other peripheral nerve (64450), and office visit (99215) provided on February 24, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were unrelated to hospice and 
the enrollee's terminal illness. 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. 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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the injection, greater occipital nerve (64405), the injection, 
other peripheral nerve (64450), and office visit (99215) provided on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services from January 8, 2020, through 
January 10, 2020, as billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the medical record does 
not support the billed diagnosis code A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 the inpatient hospital 
services as billed. Our reviewer says that the documentation does not support the billed diagnosis code A41.9, 
defined as sepsis, unspecified organism. Our physician reviewer found that the review indicates that the 
enrollee was a then, 67-year-old who presented to the emergency room with tachycardia and shortness of 
breath. The patient was tachypneic, a computed tomography angiogram did not show a pulmonary embolus but 
did show bilateral infiltrates. The member was treated with antibiotics and hydration. In this case, the diagnosis 
of sepsis was not supported in the clinical documentation for this encounter utilizing Sepsis 3 criteria. The 
review has determined that the documentation did not support the billed diagnosis code A41.9, defined as 
sepsis, unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services from January 8, 2020, through January 10, 2020, as billed with diagnosis 
code A41.9.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the stress test provided on March 10, 2022. 
 
You asked the Plan to waive the copayment for the stress test. You say that you were told the stress test would 
qualify as a basic diagnostic test. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
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 $200 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
 
  You have been asked to pay $200 for the stress test. The stress test falls within the Outpatient hospital 
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 the stress test provided on 
March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal procedures (D4999 x2) provided on 
April 7, 2022. 
 
You asked the Plan to pay for the periodontal procedures. You say that you believe this is unfair because the 
provider should have verified your coverage with the insurance company before performing the x-rays. The 
Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan 
also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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, 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 two 
periodontal procedures (D4999 x2) provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on May 25, 2021, and 
June 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from the enrollee's primary care physician. 
 
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, pre-approved care, or when there is a referral from the enrollees PCP. 
 
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 psychotherapy services provided on May 25, 
2021, and June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit on December 10, 2021 
and February 11, 2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost of the copayments is $30 per telehealth visit. 
 
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 $30 
copayment for a telehealth visit.  
 
You have been asked to pay a $30 copayment for a telehealth visit. A telehealth visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 a telehealth visit on December 10, 2021 and February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a garment-type automatic external 
defibrillator (K0606) provided on September 17 to November 17, 2021. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were not 
informed upfront of the cost of the services at issue. The Plan denied your request. The Plan says the correct 
coinsurance was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for durable medical equipment.  
 
The enrollee has been asked to pay $586.29, or 20% of the Medicare-allowed charge of $2931.45, for each 
month of a 3-month rental of an automatic external defibrillator. An automatic external defibrillator falls within 
the "Durable medical equipment (DME) and related supplies" benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a garment-type automatic external defibrillator (K0606) provided on 
September 17 to November 17, 2021.  
 
Your complaint about not receiving clear communication from a representative of the Plan about the enrollees 
cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 vaccine provided to the enrollee on November 17, 2021. 
 
You asked the Plan to pay for the vaccine. You say that you cannot provide a free service in the wake of the 
pandemic. The Plan denied your request. The Plan says that this service is not covered. 
 
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 plan has not submitted a valid denial in this case. The COVID-19 vaccine is 
covered by Medicare at this time. The plan has not submitted a clear reason for why this vaccine should not be 
covered. Therefore, we decided that the Plan has to pay for the COVID-19 vaccine provided to the enrollee on 
November 17, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on February 25, 2022 from a non-
Plan approved provider. 
 
You asked the Plan to pay for the hearing aids. You say that you called member services in February to inquire 
about hearing aid benefits and were advised you could go anywhere to get hearing aids. The Plan denied your 
request. The Plan says this request is unable to be approved. The Plan also says that you were not advised you 
could go anywhere to get hearing aids during your call with the Plan. 
 
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 you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. 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 provided on February 25, 2022 from a non-Plan approved provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (D0427) and ground mileage (A0425) provided on October 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be reprocessed and paid. 
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 October 2, 2020. 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 ambulance 
service, advanced life support, emergency transport (D0427) and ground mileage (A0425) provided on October 
24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on March 3, 2022. 
 You asked the Plan to pay for the CT scan 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 with an 
appropriate modifier required to bypass the NCCI edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) 
provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental mouth guard. 
 
You asked the Plan to pre-approve the dental mouth guard. You say that the enrollee is currently undergoing 
radiation therapy for high grade carcinoma of the parotid gland. You say that the enrollee has been 
experiencing grinding of the teeth and jaw pain due to radiation and previous surgery. You say that the enrollee 
needs to be fitted for an oral night guard to prevent further damage to her teeth and jaw. The Plan denied your 
request. The Plan says in order for the requested device to be covered, the enrollee would need to have clinical 
notes that show the device is a mandibular advancement device used to treat obstructive sleep apnea, in a 
patient with a bona fide diagnosis of obstructive sleep apnea. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental mouth guard.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the IRF services because you need 
rehabilitative services. The Plan denied your request. The Plan says the records do not show that the enrollee 
needs to see a rehabilitation doctor three times per week, and they do not need an intensive rehabilitation team. 
The enrollee also does not need three hours of therapy per day. The enrollee can safely receive the services they 
need in other settings, for example a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. At the current level of function, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
 
IRF admission is not medically necessary based lack of medical complexity and acute rehabilitation nursing 
needs and high functional level. Documentation does not support the medical necessity for admission to an 
IRF. 
 
While the enrollee may benefit from continued physical therapy and occupational therapy, her rehabilitation 
needs can be safely provided in a lower intensity and alternate setting such as in home with continued 
therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 24, 2021. 
 
You asked the Plan to pay for an office visit. You say that that the enrollee was referred to the clinic to follow-
up for heart issues. The Plan denied your request. The Plan says the out-of-network services were 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 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 an office visit provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for procedures on eye (00140) provided on 
January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 anesthesia for procedures on eye (00140) 
provided on January 6, 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 the emergency anesthesia rendered on August 30, 2021. 
 
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 covered. 
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency anesthesia rendered on August 30, 2021.