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

 
We decided that the Plan does not have to pay for the hearing aids (V5261) and hearing aid or assistive 
listening device/supplies/accessories (V5267) provided on May 20, 2022, by a non-Plan approved hearing aid 
provider. 
 
You asked the Plan to pay for the hearing aids and hearing aid or assistive listening device/supplies/accessories. 
You say that you are granted two hearing aids every three years with your insurance policy, and you would like 
to be reimbursed for these hearing aids. The Plan denied your request. The Plan says these items are not 
covered because you did not receive them from a Plan-approved 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 you use the Plan's approved 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 and hearing aid or assistive listening device/supplies/accessories have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) and hearing aid or 
assistive listening device/supplies/accessories (V5267) provided on May 20, 2022, by a non-Plan approved 
hearing aid provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital surgery services provided on January 6, 2022, to 
January 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital surgery services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a 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 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 hospital surgery services provided on January 6, 
2022, to January 8, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on November 
9, 2021. 
 
You asked the Plan to pay for the testing services. You say that the codes are covered by Medicare for the date 
of service. The Plan denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the gene panel was not billed with a single code as required. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel testing provided 
on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on July 5, 2022 
 
You asked the Plan to waive the copayment for an eye exam. You say that you are asking for a reimbursement 
of the copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $20 
copayment for vision care.  
 
You have been asked to pay a $20 copayment for an eye exam. This item/service falls 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 an eye exam provided on July 5, 
2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92310), comprehensive contact lens 
evaluation (S0592), and contact lenses (V2521) provided on June 3, 2022. 
 
You asked the Plan to pay for the contact lens fitting, comprehensive contact lens evaluation, and contact 
lenses. You say that you have paid for this charge, and would like to know if you should be refunded. The Plan 
denied your request. The Plan says these services are only allowed once per two calendar years. The Plan also 
says the records show you already received glasses or contact lenses within this time period. 
 
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 $200 every two calendar years for eyeglass frames or contact lenses.  
We looked at the file and the Plan's rules. Specifically, the record shows that you exhausted your eyewear 
allowance benefit on May 20, 2021. Based on this information, we decided that the Plan's rules for coverage of 
the contact lens fitting, comprehensive contact lens evaluation, and contact lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting (92310), comprehensive 
contact lens evaluation (S0592), and contact lenses (V2521) provided on June 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you live in 
an independent senior living facility, fell, and it is standard protocol for the facility to call the ambulance in 
such a situation. You also say that this should be considered preventive care in avoiding unnecessary 
emergency room and hospital costs by doing this evaluation. The Plan denied your request. The Plan says you 
were evaluated and treated by an ambulance crew to address a fall. The Plan also says that you were not 
transported to the emergency department based on your refusal. 
 
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 April 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report shows that you refused to be transported by the ambulance. Therefore, we decided that the Plan 
does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the lab testing was conducted in good faith. 
The Plan denied your request. The Plan says authorization was not obtained. 
 
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 file shows that the enrollee received definitive drug testing. The provider in this case is not a network 
provider with the Plan. The Plan had network providers available who could have provided the lab services at 
issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would 
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 2, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cancer panel testing provided on June 16, 2022. 
 
You asked the Plan to pay for the testing services. You say that the results impact clinical decision making. The 
Plan denied your request. The Plan says the testing is not approved. 
 
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. The medical records show that the testing at issue is not FDA 
approved. There are insufficient records from the treating provider that show a clinical indication for the 
testing. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the cancer panel testing provided on June 16, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on August 
13, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code A0425 has an MUE of 250. The services were billed with 345 units, exceeding the 
maximum amount allowed. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation services provided on August 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are functioning at a home care level. You do not require daily skilled therapy. 
There are no daily skilled nursing needs. Admission to SNF is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that there was 
no need for transportation, and you would like to know why you are being charged $350 for nothing. The Plan 
denied your request. The Plan says you received treatment on-site at your home and refused transportation to 
the hospital. 
 
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 May 24, 2022. 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 with no 
transport (A0998) provided on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 physician's supervision 3 times a 
week in an IRF. There are no 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 a multidisciplinary approach in an IRF. While the enrollee may benefit from continued physical 
therapy, and occupational therapy, the enrollee's rehabilitation needs can be safely provided in a lower intensity 
and alternate setting. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9374 billed for date of service March 5, 
2022 to March 18, 2022. 
 
You asked the Plan to pay for procedure code S9374. You say that the services were provided in good faith, 
and you would like this claim to be reprocessed for correct payment. The Plan denied your request. The Plan 
says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9374 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9374 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9374 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9374 billed for date of service March 5, 2022 to March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the eyeglasses purchased on March 28, 2022. 
 
You asked the Plan to pay in full for the eyeglasses. You say that at the time of this purchase, you were advised 
that these glasses were on sale, and that you would owe nothing for them. The Plan denied your request. The 
Plan says your benefit allowance of $200 was exhausted on this purchase. The Plan also says that this claim 
was processed 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 up to a $200 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that your $200 allowance was exhausted on this 
purchase, and a 20% discount was also applied, leaving you responsible for a total of $137.60 for this purchase. 
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay in full for the eyeglasses purchased on March 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on June 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would consider the hearing aids you received 
to be Premium Tech, and would like to be reimbursed a total of $1,200 for your new hearing aids. You also say 
that you did not find in the Plan's booklet where a certain vendor or particular make of hearing aids must be 
adhered to, but only the copayments offered. The Plan denied your request. The Plan says the treating provider 
is not in-network with the Plan, and you do not have OON benefits. 
 
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 approved 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 (V5261) purchased on June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the acute IRF setting. You say that further delay in care will have a detrimental effect on the enrollee's 
safety, ability to recover to the fullest extent, be discharged to a community setting and stay in that community 
setting, averting unplanned readmissions. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 acute 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 May 6, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you did not know the provider was out-of-network. 
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 May 6, 2022, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment provided from January 3, 
2022 to May 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatment. You say that the enrollee had no choice but to 
seek treatment with you, even though you are OON. You also say that you believe the Plan should pay these 
claims in full. The Plan denied your request. The Plan says these services are not authorized because the 
treating provider is a non-network provider, and the enrollee self-directed for care. The Plan also says that the 
enrollee's primary care provider did not refer for services, and no medical necessity for an OON provider, such 
as an urgent or emergency situation, has been documented.  
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 medication assisted treatment provided from 
January 3, 2022 to May 30, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing provided on November 2, 
2021. 
 You asked the Plan to pay for the testing provided. You say that the records support medical necessity. The 
Plan denied your request. The Plan says tests must not be unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The information in the case file shows that more than 5 pathogen 
targets were tested. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for  the respiratory pathogen testing provided on 
November 2, 2021.