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

 
We decided that the Plan does not have to pay for heated socks purchased on March 5, 2022. 
 
You asked the Plan to pay for heated socks. You say that you need heated socks to help with your health issues. 
The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may offer over-
the-counter (OTC) items as a supplemental benefit under Part C. OTC items include non-prescription drugs - 
also known as OTC drugs  and health-related items. The Plan offers a Wellness Wallet benefit that covers 
fitness, naturopathic services, acupuncture, nutrition/dietary education, weight management programs, 
eyewear, and face masks. 
 
We looked at the file and Medicare rules. The socks that you purchased do not fall within any of the categories 
covered by the Plans Wellness Wallet benefit. Based on this information, we decided that Medicare rules for 
coverage of heated socks have not been met. Therefore, we decided that the Plan does not have to pay for 
heated socks purchased on March 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for outpatient vision services provided on April 3, 2021. 
 
You asked the Plan to pay for outpatient vision services. You say that you sent in all of the required 
documentation in May or June of 2021. The Plan denied your request. The Plan says that the required 
documentation has not been sent into the Plan. 
 
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 a $150 allowance every year for eyewear for in-network or out-of-network services.  
 
We looked at the file and the Plan's rules. The Plan contract states that you must pay up front and submit a 
claim for out-of-network vision care. However, the Plan contract does not state that an itemized receipt to show 
proof of payment is required. The record shows that you submitted a claim for the out-of-network vision care. 
Based on this information, we decided that the Plan's rules for coverage of outpatient vision services have been 
met. Therefore, we decided that the Plan has to pay for outpatient vision services provided on April 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480.  
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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88112, 88305, 88312, and 88361 billed for 
date of service February 11, 2022. 
 You asked the Plan to pay for procedure codes 88112, 88305, 88312, and 88361. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88112, 88305, 88312, and 88361 has a Professional/Technical indicator of 1. This means 
that CPT codes 88112, 88305, 88312, and 88361 has both a professional and technical component. In this case, 
CPT codes 88112, 88305, 88312, and 88361 has not been billed with an appropriate modifier to indicate the 
professional component. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88112, 88305, 88312, and 88361 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88112, 88305, 88312, and 88361 billed for date of service February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for facial/oral prosthesis preparation surgery 
provided on April 27, 2022. 
 
You asked the Plan to waive the cost-sharing for facial surgery. You say that you were not aware that this 
provider was out-of-network, and if you had known you would have picked an in-network provider. The Plan 
denied your request. The Plan says the cost-sharing amounts you are being charged are correct. 
 
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 $675 
deductible and 50% coinsurance for out-of-network outpatient surgery at an ambulatory surgical center. At the 
time this claim was processed, $497.20 of the $675. The allowed amount of the claim is $617.61, resulting in a deductible amount of $177.80 because this met the $675 total deductible for 2022. After the deductible was 
met, the remaining allowed amount of the claim is $439.81, resulting in a coinsurance amount of $219.90. 
Therefore, your total cost-sharing responsibility is $397.70. 
 
You have been asked to pay $675 deductible and 50% coinsurance for facial surgery. Facial surgery falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 cost-sharing for facial/oral 
prosthesis preparation surgery provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (97112, Q9967, 77002, 20610, J7320) 
provided January 5, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 97112, Q9967, 77002, 20610, & J7320 are not supported in the medical record. 
Specifically, the clinical records provided do not include procedure reports that document these procedures 
being performed. Based on this information, we decided that Medicare rules for coverage of the outpatient 
services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services 
(97112, Q9967, 77002, 20610, J7320) provided January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on May 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 outpatient visit provided on May 7, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service coded as 
99441 provided on March 7, 2022. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not 
support the services billed. 
 
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 99441 is Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 We find that CPT code 99441 is not supported in the medical record. Specifically, the documentation shows 
that the provider billed and was paid for an evaluation and management (E/M) service code, 99215 on February 
28, 2022. This is within the seven days allowed per the Telephone E/M services and thus is included in the 
previously billed E/M code. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the telephone evaluation and management service have not been 
met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management 
service coded as 99441 provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided March 23, 2022 
 
You asked the Plan to pay for the laboratory service. You say that you are an independent diagnostic laboratory 
that tests Pathology, medication management and toxicology samples sent from clinics and providers for 
patients they have determined require such testing. The Plan denied your request. The Plan says PCR testing is 
considered unproven and not medically necessary. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing provided March 23, 2022
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Breast Cancer Index (BCI) gene expression test provided 
on January 24, 2022. 
 
You asked the Plan to pay for the BCI test. You say that this is a Medicare-covered test that is supported. The 
Plan denied your request. The Plan says the date of service reported is incorrect. In addition, the required Z-
code was not reported on this claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The required Z-code was not found on the claim submitted. Based on 
this information, we decided that Medicare rules for coverage of the BCI test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Breast Cancer Index (BCI) gene expression test provided on 
January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visit provided on April 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for specialist office visit. You say that the provider told you, you had to pay for the 
appointment since the doctor is not affiliated with your Plan. You say that you did not know you had to request 
authorization prior to your visit. The Plan denied your request. The Plan says the services were provided out-
of-network and were not approved in advanced. 
 
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 specialist office visit provided on April 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 laboratory services provided on May 4, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tumor Origin test provided on December 1, 2021. 
 
You asked the Plan to pay for the Tumor Origin test. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says that though the original denial was due to Medicare criteria not being met, it 
was determined that the date of service for lab testing must be the date the sample was taken. Since this claim 
did not report the sample collection date as the date of service, it is not correctly billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not assess whether the criteria for an exception were met for the 
reported date of service. In this case, the sample was a biopsy of the tumor which would have been performed 
in the hospital setting. The Plan did not provide any evidence to show that the sample was not taken in a 
hospital outpatient encounter which would allow for the reported date of service to be the date when the testing 
was performed, as was reported in this case. Therefore, we decided that the Plan has to pay for the Tumor 
Origin test provided on December 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories 
(K0823, E2365x2, E0973, K0108, E0978, E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that it is noted that the 
requested wheelchair, is a good option for a power chair to meet all of your independent mobility needs. The 
Plan denied your request. The Plan says the requested power wheelchair with accessories remains upheld as 
they are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is inadequate 
documentation that you can safely operate a power mobility device in your home. Provided records indicate 
your medical provider has recommended a mental status evaluation before approving the power wheelchair. 
Provided records do not document the results of a mental status examination performed by a physician or 
advanced practice provider to more clearly assure that you are safe to use the requested power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair and accessories (K0823, 
E2365x2, E0973, K0108, E0978, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management provided on March 31, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management. You say that you should not need a referral or an 
authorization for the service that was billed. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 chronic care management provided on March 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for COVID-19 testing (G2023, U0004, U0005) billed for date of service 
April 28, 2022. 
 
You asked the Plan to pay for COVID-19 testing. You say that the services at issue were billed correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan has issued a denial for durable medical equipment (DME). 
The services at issue are not DME. It is the Plan's responsibility to substantiate its denial with evidence. In this 
case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for COVID-19 testing (G2023, U0004, U0005) billed for date of service April 28, 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.