Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 March 29, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81206, 81235, 81292, 81301, 81321) 
provided May 6, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The 
Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The records do not show that the testing was ordered by the enrollee's 
treating physician. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81206, 
81235, 81292, 81301, 81321) provided May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G power-assisted arm brace. 
 
You asked the Plan to pre-approve the MyoPro Motion G arm brace. You say that it is felt that this would be 
beneficial for the enrollee's level of function. The Plan denied your request. The Plan says there is not sufficient 
evidence to support the medical necessity of this device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion G arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. Although records from the device manufacturer/vendor argue medical necessity of the 
requested device, no records from the enrollee's actual treating provider clarify why the requested device is the 
most appropriate treatment for the enrollee's condition. 
 
 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 MyoPro Motion G arm brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G power-assisted arm brace.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the facet joint RFA procedure. You say that this should be approved 
because prior RFAs have been beneficial. The Plan denied your request. The Plan says since the RFA provided 
no relief, no further RFAs can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA procedures are covered when prior 
procedures produce at least 50% relief for six months.  
 
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 facet joint RFA procedure. Our 
reviewer says that the requested procedure is not reasonable and necessary. Our physician reviewer found the 
RFA did not provide any relief and therefore should NOT be repeated. The request is not medically reasonable 
or 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 the facet joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat facet joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radical resection of tumor (21016) provided on August 5, 
2021. 
 
You asked the Plan to pay for the radical resection of tumor (21016). You say that CPT code 21016 was added 
per the physician to represent the radical face resection. You say that the notes should be reviewed and 
additional payment for CPT code 21016 reconsidered. The Plan denied your request. The Plan says procedure 
code 21016 is not supported by the medical records submitted. 
 
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 21016 is radical resection of tumor (eg, sarcoma), soft 
tissue of face or scalp; 2 cm or greater. 
  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 radical resection of tumor (21016). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the medical record documents squamous cell carcinoma. In this case, there is a more appropriate 
code to report for this procedure. 
 
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 radical resection of tumor (21016) have not been met. Therefore, we 
decided that the Plan does not have to pay for the radical resection of tumor (21016) provided on August 5, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on January 11, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not given oral medications. 
You say that you did receive medications through an IV. You also say that you cannot give yourself 
medications through the IV and therefore these should be covered. The Plan denied your request. The Plan says 
the claim processed correctly. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting on January 11, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81301, 81311) provided September 20, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. In this case, multiple unbundled codes were submitted for a single 
panel. 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 (81206, 81301, 81311) provided 
September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses (S0500) provided on December 
21, 2021. 
 You asked the Plan to pay for the disposable contact lenses. You say that the last time you used this benefit was 
in 2019, so you should be eligible to use it again. The Plan denied your request. The Plan says this request for 
disposable contacts is denied due to exceeding the benefit maximum. 
 
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 $150 per calendar year for eyewear from a Plan-approved Vision Care 
participating provider. 
 
We looked at the file and the Plan's rules. The record shows that two requests for contacts were submitted on 
the same date of service of December 21, 2021. The conventional contacts were applied to your benefit of $150 
per calendar year benefit, and your $150 eyewear allowance has been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the disposable contact lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for the disposable contact lenses (S0500) provided on December 21, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 28, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says eye refractions are only covered by your plan if performed by a 
participating provider and performed as a routine screening.  
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 eye refractions are provided during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the eye refractions were performed during a 
medical vision check for age-related nuclear cataract, bilateral. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction (92015) provided on March 28, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (99283) provided October 23, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says that the claim is a duplicate. 
 
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. No documentation was provided to show this was a duplicate claim. There is no 
claim number provided to show these services were previously paid. Therefore, we decided that the Plan has to 
pay for emergency room services (99283) provided October 23, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (01400) provided January 26, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 anesthesia services. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found patients undergoing meniscal surgery are typically put under general anesthesia, although 
regional nerve block may also be considered. In this case, the service is considered medically reasonable and 
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 the anesthesia services have been met. Therefore, we decided that the Plan has 
to pay for anesthesia services (01400) provided January 26, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 test kits purchased on December 17, 
2021, and December 21, 2021. 
 
You asked the Plan to pay for at-home COVID-19 tests. You say that these tests were necessary because you 
were showing symptoms of COVID-19. The Plan denied your request. The Plan says these tests are an over-
the-counter item which were not eligible for coverage by Medicare or the Plan on the dates in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 tests is an OTC item which was not eligible for coverage on the dates in question. Therefore, we 
decided that the Plan does not have to pay for at-home COVID-19 test kits purchased on December 17, 2021, 
and December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 22, 
2022. 
 
You asked the Plan to pay for these services. You say that the services were rendered in good faith. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, of the abdomen and pelvis; with 
contrast material(s) (74177) rendered by the out-of-network (OON) provider on February 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the computed tomography, of the abdomen and pelvis; with contrast material(s) 
(74177) rendered by the out-of-network (OON) provider on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2300) provided on September 30, 
2021. 
 You asked the Plan to pay for the eyeglasses. You say that you have used this provider in the past and were 
able to receive reimbursement without issue. The Plan denied your request. The Plan says this provider is not 
part of the Plan's vision network. You must see an in-network vision provider to receive routine vision benefits. 
 
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 received from an in-network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's network. 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 for the eyeglasses (V2025, V2300) provided on September 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on July 22, 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. The rules say that payment for anesthesia services is made to the 
physician who personally performed the entire anesthesia service alone or a qualified nonphysician anesthetist. 
 
We looked at the file and Medicare rules. The file shows that the anesthesia services were not performed by a 
physician or qualified nonphysician anesthetist. 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 
anesthesia services rendered on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of nondystrophic nails and the debridement of 
nails provided on January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the trimming of nondystrophic nails and the debridement of nails. You say that 
authorization was not obtained prior to seeing this patient since it is the nursing facilities responsibility to get 
authorizations for their patients. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and the services were not referred by a network provider. The Plan also says that they 
have also determined that these services are not urgent or emergent, nor were they 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 trimming of nondystrophic nails and the 
debridement of nails provided on January 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam services (92014, 
92250) provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for medical vision care. You say that this was a diabetic eye exam 
which should be covered at no cost to you. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $35 copayment for medical vision care. The services in question were billed as a 
medical/diagnostic eye exam and the diagnoses submitted for this claim are medical in nature. The medical 
records provided do not support that this was a diabetic retinopathy screening provided to an enrollee with 
diabetes but no other symptoms of diabetic retinopathy. Therefore, these services fall within the Medicare-
covered eye exams to diagnose and treat diseases and conditions of the eye 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 medical eye exam services (92014, 92250) provided on March 
28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transport (A0427) and ground 
mileage (A0425) provided on December 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. 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 emergency ambulance transport (A0427) and ground 
mileage (A0425) provided on December 6, 2020.