Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan (72125, 70450, G1012) provided on August 15, 
2022. 
 
You asked the Plan to pay for the CT scan. 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. 
 
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 a CT scan (72125, 70450, G1012) provided on August 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a return office visit provided on July 05, 
2022. 
 
You asked the Plan to waive the copayment for a return office visit. You say that this should have been an 
annual, you feel this is not your fault and want the copay waived. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a return office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 return office visit provided on July 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens, the ultraviolet lens, and the anti-
reflective coating per lens provided on October 8, 2022. 
 
You asked the Plan to pay for the enhancement services. You say that you needed another pair of lenses after 
you were diagnosed with macular degeneration. The Plan denied your request. The Plan says the services are 
not covered 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 does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the enhancement services have not been met. 
Therefore, we decided that the Plan does not have to pay for the polycarbonate lens, the ultraviolet lens, and the 
anti-reflective coating per lens provided on October 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is hemodynamically stable 
for transfer to the LTACH. You say the enrollee will need constant monitoring to maintain stability and this 
cannot be achieved at a lower level of care. The Plan denied your request. The Plan says criteria for admission 
to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has had a complicated course and has ongoing acute medical issues 
that still require acute care services. The enrollee does not require services at the LTACH that are not available 
at the acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the procedure was rendered in the appropriate 
place of service. The Plan denied your request. The Plan says an inappropriate place of service was billed. 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 85060 was billed with an outpatient hospital place of service code. Separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 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 procedure code 85060 billed for date of service June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 1, 2022, to July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on July 1, 2022, to July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on August 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that the provider is not responsible to obtain 
authorization. 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
eye exam. We found no exception that would require the Plan to pay for the eye exam. Therefore, we decided 
that the Plan does not have to pay for the eye exam provided on August 29, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
June 30, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you want the unaffordable hearing aid expense to 
be covered in-network. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 provided by the network provider.  
 
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. Specifically, the out-of-network provider is not the Plans 
approved vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided by an 
out-of-network provider on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on September 6, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with 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 outpatient diagnostic tests/x-ray services.  
 
You have been asked to pay a $20 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/x-ray 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 x-ray 
services provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment (E1392), provided on August 25, 
2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not covered for purchase. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, A/B MACs 
(A) and (HHH), and DME MACs pay a monthly fee schedule amount per beneficiary. Unless otherwise noted 
below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of 
equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for the oxygen equipment (E1392), provided on August 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency 
transport, level 1 provided on September 9, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1. You 
say to please review the submitted medical records as this was an urgent transport. The Plan denied your 
request. The Plan says the claims was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized 
diagnostic or therapeutic services not available at the facility where the patient is an inpatient.  
 
The enrollee was a hospital inpatient at the time of service and was transported to a separate facility for testing 
which means this ambulance service is included in the inpatient payment and is not separately paid by 
Medicare.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service, advanced life support, emergency transport, level 1 have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, 
emergency transport, level 1 provided on September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentisis provided on September 
20, 2022. 
 
You asked the Plan to waive the copayment for an arthrocentisis. You say that you disagree with how the 
service provided was categorized and the $300 copayment charged. 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 $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for an arthrocentisis. This item/service falls within the 
outpatient surgery 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 arthrocentisis 
provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 12, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on 
March 10, 2022, and April 5, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675), provided on March 10, 2022, and April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames and the progressive lens provided on 
September 21, 2022. 
 You asked the Plan to pay for the Plan does not cover out-of-network vision care services.. You say that you 
think the Plan should consider paying for the frames and lenses because an in-network doctor would still have a 
copayment. The Plan denied your request. The Plan says out-of-network services are not covered. 
 
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 received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network Based on this 
information, we decided that the Plan's rules for coverage of the Plan does not cover out-of-network vision care 
services. have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames and 
the progressive lens provided on September 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records show that this service was 
performed, so this claim was denied in error. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item with the RT modifier instead of billing a single line item with the bilateral modifier as is required. Based 
on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service 
September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient visit provided on June 15, 2022. 
 
You asked the Plan to waive the copayment for outpatient visit. You say that you are requesting 
reconsideration stating that there is a billing error. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 copayment for Outpatient surgery, including services provided at hospital facilities and 
ambulatory surgical centers.  
 
The enrollee has been asked to pay $179.29 which is less than the $250 copayment for outpatient visit. This 
item/service falls within the Outpatient surgery, including services provided at hospital facilities and 
ambulatory surgical centers 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 copayment for 
outpatient visit provided on June 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
20, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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. The code at issue 
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 
70450 billed for date of service September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), Freestyle Libre 2 
(K0553), and sensors (K0554). 
 
You asked the Plan to pre-approve the CGM. You say that your doctors have recommended you use this. You 
say that you are not on insulin. You say that you are afraid of needles and have a challenging time using a 
lancet device. You also say that having this device will allow you to comply with your doctors. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM), Freestyle Libre 2 (K0553), and sensors 
(K0554).
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 25, 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 25, 
2022.