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

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92014) provided on 
November 7, 2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you went to the eye doctor 
for a routine exam but were billed for a diagnostic exam. You also say that you do not believe you are 
responsible for a copay when your benefits cover one routine eye exam every year. The Plan denied your 
request. The Plan says the benefit applied correctly in accordance with your Evidence of Coverage. 
 
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. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received a comprehensive eye 
exam (checks the overall health of eyes and screen for eye diseases) which is not a routine service. Based on 
this information, we decided that the Plan's rules for coverage of the medical eye exam have not been met. 
Therefore, we decided that the Plan does not have to waive the copayment for the medical eye exam (92014) 
provided on November 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Praluent injection. 
 
You asked the Plan to pre-approve Praluent. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Praluent 
injection.  
 Benefits for Praluent 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75889 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 75889. You say that the enrollee had multiple exams on this date 
of service. You also say that you would like this claim to be reconsidered for processing. The Plan denied your 
request. The Plan says payment for code 75889 is bundled into payment for code 37200. 
 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 75889 
is a column II code to column I code 37200. 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 procedure code 75889 billed for date of service June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 99310) 
provided to the enrollee on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the procedure code billed does not meet the associated place of service (POS) 13  Assisted 
Living Facility. 
 
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 99310 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded." 
 
We find that CPT code 99310 is not supported in the medical record. Specifically, this code is not appropriate 
for a patient in an assisted living facility. 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 
subsequent nursing facility care (procedure code 99310) provided to the enrollee on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography (92250), or pay more for the frames 
(V2020), single vision lens (V2100), polarization (V2762), and polycarbonate or equal lens (V2784) provided 
on September 2, 2022. 
 
  You asked the Plan to pay for the fundus photography, and to pay more for the frames, single vision lens, 
polarization, and polycarbonate or equal lens. You say that you paid out of pocket at the store for what was not 
covered. You also say that you do not owe the provider or the Plan anything. The Plan denied your request. The 
Plan says the claim will not pay out the $200.00, but deducts it from the total retail price/submitted charge to 
come up with your remaining responsibility. The Plan also says that fundus photography is not covered for 
routine supplemental 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 up to $200 for the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses once per year. The Medicare rules also say that say that intraocular photography is covered when used 
for the diagnosis of such conditions as macular degeneration, retinal neoplasms, choroid disturbances and 
diabetic retinopathy, or to identify glaucoma, multiple sclerosis and other central nervous system abnormalities. 
 
We looked at the file and the Plan's rules. The record shows that the total charge for your glasses was $308.95, 
and the Plan paid the full $200 allowance for this purchase. You received a 20% discount, and you are 
responsible for the remaining balance of $87.16 for the eyewear. The record also shows that the fundus 
photography is not covered because you received this service for diagnosis code H53.009, defined as 
Unspecified amblyopia, unspecified eye, which is not a covered diagnosis for this service. Based on this 
information, we decided that the Plan's rules for coverage of the fundus photography, frames, single vision 
lens, polarization, and polycarbonate or equal lens have not been met. Therefore, we decided that the Plan does 
not have to pay for the fundus photography (92250), or pay more for the frames (V2020), single vision lens 
(V2100), polarization (V2762), and polycarbonate or equal lens (V2784) provided on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and eye refraction (92015) provided 
on June 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction. You say that your insurance has not changed in 
the last several years and this eye exam service was provided in June 2021 without any issue. You also say that 
you received no change in coverage because you qualify for medical assistance, and do not understand why this 
has not been taken care of. The Plan denied your request. The Plan says you went to an OON provider for an 
eye exam, and no prior authorization was on file for this service. The Plan also says the June 2021 claim was 
paid in error, as the provider was not in-network for that date of service. 
 
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 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 eye exam (92014) and eye refraction (92015) 
provided on June 29, 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 laboratory services related to end-stage renal disease 
(ESRD) provided on September 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and eye refraction (92015) provided 
on March 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction. You say that you were unaware you needed pre-
approval. You also say that the facility you were treated at says they are in-network. The Plan denied your 
request. The Plan says you went to an OON provider for an eye exam, and per the Evidence of Coverage, eye 
exams are not covered when seeing an OON 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 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 eye exam (92014) and eye refraction (92015) 
provided on March 3, 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 laboratory services related to end-stage renal disease 
(ESRD) provided on August 30, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on August 
30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0621), deluxe frames (V2025), and progressive lenses (V2781) provided on August 25, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine ophthalmological examination, deluxe frames, and progressive lens. 
You say that you are paying a premium for your eye exam and dental. You also say that you would like 
payment for the eye exam and bifocal lenses. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says there is no coverage when services are rendered by a non-
participating 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 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 routine ophthalmological examination 
including refraction (S0621), deluxe frames (V2025), and progressive lenses (V2781) provided on August 25, 
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 laboratory services related to end-stage renal disease 
(ESRD) provided on July 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on July 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on August 9, 2022, 
by an out-of-network provider. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 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 a domiciliary, rest home visit provided on August 9, 2022, by an 
out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 21, 
2022, to August 19, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee does not meet 
the clinical requirements to be approved. 
 
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 pay for 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 21, 2022, to August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and anti-reflective coating 
(V2750) purchased on September 26, 2022. 
 
You asked the Plan to pay for the deluxe frames and anti-reflective coating. You say that a distinction was not 
called to your attention relative to frames. You also say that you felt the added feature of anti-glare seemed 
important for night driving safety. The Plan denied your request. The Plan says the purchase for the base frame 
was processed and covered by the Plan. The Plan also says you added deluxe frames and anti-reflective coating 
which are non-covered options. 
 
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 standard frames and lenses as defined by Medicare after cataract surgery. 
 We looked at the file and the Plan's rules. The record shows that you received deluxe frames and anti-reflective 
coating, which are upgrades that are not covered. Based on this information, we decided that the Plan's rules for 
coverage of the deluxe frames and anti-reflective coating have not been met. Therefore, we decided that the 
Plan does not have to pay for the deluxe frames (V2025) and anti-reflective coating (V2750) purchased on 
September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on October 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on November 8, 2022. 
 
You asked the Plan to pay for an eye refraction (92015). You say that the provider did not tell you much about 
the paper you were signing. The Plan denied your request. The Plan says the member had a diagnostic eye 
examination on the date of service in question, not a routine eye exam. The Plan also says that the member 
signed consent that he is responsible to pay for any uncovered services including a refraction.  
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 the eye refraction is part of the routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say one routine eye examination, including refraction, 
is covered every calendar year. The record shows that this eye refraction was not a part of the routine eye 
examination. Based on this information, we decided that the Plan's rules for coverage of a medical eye 
refraction (92015) have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on November 8, 2022.