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

 
We decided that the Plan has to pay for fluoroscopic guidance (77001) provided on July 12, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because 
the procedure code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
In this case, we have confirmed that code 77001 is a column II code to column I code 49083; however, the case 
record shows that the codes were billed separately under two providers of different specialties. NCCI edits do 
not apply to physicians of different specialties. Based on this information, we decided that Medicare rules for 
coverage of fluoroscopic guidance have been met. Therefore, we decided that the Plan has to pay for 
fluoroscopic guidance (77001) provided on July 12, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2100) provided on January 3, 2022. 
 You asked the Plan to pay for the eyeglasses. You say that you did not know where to go to use your insurance 
benefits. You say the provider told you they did not take your insurance, but you could try and get 
reimbursement from your plan for these services. The Plan denied your request. The Plan says out-of-network 
services are not covered by your Plan. The Plan also says they are reviewing your other concerns as a separate 
grievance. 
 
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 only when they are received from a participating provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified routine 
vision vendor 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 
(V2020, V2100) provided on January 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for COVID-19 testing (97635) provided by an in-network 
provider on September 27, 2021. 
 
You asked the Plan to hold you harmless for COVID-19 testing. You say that you should be reimbursed the 
whole cost for this test. The Plan denied your request. The Plan says that this was covered according to the 
allowable charges. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also say when enrollees obtain plan-covered services in an HMO, PPO, 
or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. 
 
You were provided COVID-19 testing by a contract provider. The file does not show that the Plan provided 
notice that COVID-19 testing would not be covered. Under Medicare rules, this means COVID-19 testing is 
considered approved by the Plan. The record also shows that the in-network provider has charged you more 
than the plan-allowed cost-sharing. Under Medicare rules, you may not be charged or held liable for more than 
plan-allowed cost-sharing. Therefore, we decided that the Plan has to hold you harmless for COVID-19 testing 
(97635) provided by an in-network provider on September 27, 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 pay for the pneumatic compression device provided on September 
22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says payment is the responsibility of the facility. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. Payment for this service would have been included under the facility claim. Payment to you for 
this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 19, 2021. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 drug testing provided on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral supplies billed for services provided from 
August 20, 2021, to August 26, 2021. 
 
You asked the Plan to pay for the billed services. You say that the codes are reimbursable. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. We find that the supplies at issue are not supported in the records. 
Specifically, the records do not show that the items were delivered/provided to the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the parenteral supplies billed for services provided from 
August 20, 2021, to August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple x-ray services provided to the enrollee on July 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this was reasonable and necessary. The Plan denied 
your request. The Plan says under Medicare rules, the request for multiple X-ray services is considered not 
medically reasonable and necessary. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has a history of gastroesophageal reflux.  
 The record indicates that the enrollee had a negative review of systems for the gastrointestinal system and an 
unremarkable relevant physical examination. The records provided does not indicate the intent to order the 
requested services. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for multiple x-ray services provided to the enrollee on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on October 20, 2021. 
 
You asked the Plan to pay for the lab testing. You say that these labs were medically necessary and separately 
payable. The Plan denied your request. The Plan says payment for lab testing related to ESRD treatment is 
included in the payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab testing provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from November 1, 2021, through 
November 19, 2021. 
 
  You asked the Plan to pay for acupuncture. You say that acupuncture is a covered benefit under the diagnosis 
of low back pain and the patient was provided acupuncture services in accordance with Medicare guidelines. 
You say that the services were medically necessary, and payment should be approved. The Plan denied your 
request. The Plan says the enrollee has already received the maximum benefit allowed for this service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan paid for 20 acupuncture visits prior to 
receiving these services. Therefore, we decided that the Plan does not have to pay for acupuncture provided 
from November 1, 2021, through November 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the chest (71045) rendered by the out-of-
network (OON) provider on December 21, 2021. 
 
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 x-ray exam of the chest (71045) rendered by the out-of-network (OON) provider 
on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray exam of the hand (73120) 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $85 
copayment for basic radiology services rendered by an in-network outpatient hospital.  
 
 
 You have been asked to pay a $85 copayment for the basic radiology service rendered by an in-network 
outpatient hospital. 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 x-ray exam of the hand 
(73120) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the scooter (K0800). 
 
You asked the Plan to pre-approve the scooter. You say that you would like reconsideration because it has been 
hard for you to move and you have fallen both inside and outside the house. The Plan denied your request. The 
Plan says due to your inability to transfer on and off safely and independently, you would not benefit from a 
scooter. 
 
The Plan follows Medicare rules. Medicare rules say that Power Operated Vehicles may be covered if the 
criteria listed in the Medicare rules section of this letter are met.  
 
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 scooter. Our reviewer says that the 
criteria for the requested K0800 scooter have not been met. The documentation does not support that the POV 
will significantly improve your ability to participate in MRADLs and that you will use it safely in the home.  
 
  
 
 
 
 Our physician reviewer found there is no evidence of a detailed objective physician performed musculoskeletal 
or neuromuscular exam supporting that your mobility limitation cannot be sufficiently and safely resolved by 
the use of an appropriately fitted cane or walker. There is no detailed objective physician examination 
supporting that you do not have sufficient upper extremity function to self-propel an optimally-configured 
manual wheelchair in the home to perform MRADLs during a typical day. The physician progress note states 
that you would not benefit from a scooter due to inability to transfer on and off safely and independently. You 
also have a diagnosis of visual disturbance and it is not clear if your vision is sufficient for safe mobility using 
a POV in the home. There is no evidence of an objective home evaluation supporting that the home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is 
provided. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the scooter (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
22, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient 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. 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 70450 billed for date of service December 22, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by an out-of-network 
(OON) provider on November 18, 2021. 
 
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. 
 
You are 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 office visit (99214) rendered by an out-of-network (OON) provider on  
November 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
rides due to having no other means of transportation. You are currently battling many different health 
conditions that prevent you from driving. The Plan denied your request. The Plan says additional trips would 
exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  We looked at your request, the records in the case file, and the rules. The records show that you have used 
fourteen (14) one-way transportation trips out of the allowed twenty (20) one-way trips approved. Once 20 trips 
are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional non-emergent routine transportation trips (A0100).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a wheeled walker with contact guard assistance and is contact guard assist for 
transfers. Provided records do not document a significant decline in the enrollees functional status compared 
to his recent baseline to necessitate daily inpatient skilled therapy services. The enrollee does not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 13, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 and therapeutic services and supplies.  
 
 
  You have been asked to pay a $20 copayment for an ultrasound. Ultrasounds fall within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 ultrasound provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 3, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient 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. 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 70450 billed for date of service January 3, 2022.