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

 
We decided that the Plan does not have to pay for the dental services provided on October 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that your provider did not notify you that they opted 
out of Medicare. The Plan denied your request. The Plan says the provider is not eligible to participate with 
Medicare. 
 
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 file shows that you received an oral exam, cleaning, and x-rays. We looked at the file, and Medicare rules. 
The provider was not eligible to provide services under Original Medicare at the time the services were 
provided. Based on this information, we decided that the Plan's rules for coverage of the dental services have 
not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulse oximetry services provided on July 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the benefit 
for this service is included in the payment for another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 
 We find that CPT code 94760 has a status indicator of T on the Physician Fee Schedule. This means that CPT 
code 94760 is not separately payable. 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 
pulse oximetry services provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe you have not been adequately 
reimbursed for these services according to the Plan's contract. The Plan denied your request. The Plan says the 
claim has processed correctly in this case. 
 
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 Plan says that you may be 
billed by the out-of-network provider for any amount greater than the payment made by the Plan 
 
We looked at the file and Medicare rules. In this case, the documentation indicates that the provider has 
charged $220 for the services rendered. Based on the Plans in-network fee schedule, the allowed amount for a 
provider to charge for services rendered was $78. The Plans cost sharing coinsurance of 50% is only 
calculated with the in-network fee of $78. Therefore, you have correctly been reimbursed the coinsurance of 
$39. Any amount over this in-network fee is what you are also liable for. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for the dental services provided on December 27, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services after September 26, 2021. 
 
You asked the Plan to pay for SNF care. You say that continuation of SNF care was medically necessary. The 
Plan denied your request. The Plan says that the enrollee no longer required skilled services and continuation of 
SNF was not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 26, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services after September 26, 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 refraction (code 92015) provided on December 2, 2021. 
 
You asked the Plan to pay for the refraction. You say that these services were urgently needed and medically 
necessary. The Plan denied your request. The Plan says refraction is a routine vision service and is only 
coverable under the enrollee's routine vision supplemental benefit.  Under this benefit, there is no coverage for 
routine vision services provided by out-of-network providers, and you are an out-of-network provider.  The 
other non-routine services provided on this date have been paid. 
 
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 routine vision services only when received from an in-network provider.  You are 
not a network provider with the Plan. 
 
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the refraction (code 92015) provided on December 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-transport ambulance services you received on 
October 20, 2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that when you tripped and fell at 
a business, the business called an ambulance.  The paramedics took your blood pressure and looked at your 
wrist.  You stated that you didn't think it was necessary to ride in an ambulance to go to the emergency room, 
so your husband drove you instead.  You feel as though this should be covered even though there was no 
transport. The Plan denied your request. The Plan says ambulance services are not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 20, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the non-transport ambulance services you received 
on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided 
from November 1, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the LTACH services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says it paid for the LTACH services until September 10, 2021. After that 
date of service, LTACH care was not medically necessary. As of that date, there were no clinical reasons why 
ongoing care could not have been provided at a skilled nursing facility, the member was medically stable and 
breathing normally on 3 liters of nasal cannula oxygen 
 
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 pay for the LTACH services. Our reviewer says that 
the requested LTACH care was not considered medically reasonable and necessary in this case. Our physician 
reviewer found for the dates of service in question, the LTACH services were not medically necessary, 
reasonable, or appropriate for the diagnosis and condition of the enrollee, and were able to be furnished safely 
and effectively at a lower level of care. 
 
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 pay for long term acute care hospital (LTACH) services provided from November 1, 2021, to 
November 30, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided on September 27, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that upon ambulance arrival this patient was intubated 
for respiratory failure. The patient was ordered to receive air transport for a higher level of care. The specialty 
of critical care is available at the sending hospital according to the sending facility's website. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were medically necessary. Our physician reviewer found the patient is a 70 
year old male who was transported via air ambulance to a higher level of care hospital for angioedema and 
acute respiratory failure due to lack of intensive care (ICU) bed availability at the sending hospital or any other 
appropriate hospitals in the state of the patient's residence. Prior to transport, the patient was intubated and 
placed on mechanical ventilation support and was stable. The documentation does support that the patient 
suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The 
documentation does support that the patient's condition was such that the time needed to transport a patient by 
ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. In addition, the documentation does support that the transferring hospital did 
not have adequate facilities (no ICU beds) to provide the medical services needed by the patient. 
 
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 air ambulance services have been met. Therefore, we decided that the Plan 
has to pay for air ambulance services provided 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from May 27, 2020, to June 8, 
2020. 
 
You asked the Plan to pay for the hospital services. You say that your hospital was hit hard by the COVID-19 
pandemic, and you did not have staff to get bills out the door. You said these services were medically 
necessary. The Plan denied your request. The Plan says you did not file your corrected claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for the hospital services was not filed until December 11, 2021. This 
means that more than one calendar year from the date of service had passed before a corrected claim was filed. 
Therefore, we decided that the Plan does not have to pay for hospital services provided from May 27, 2020, to 
June 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on May 27, 2021, and 
June 8, 2021. 
 
You asked the Plan to pay for surgical pathology services. You say that the patient was not in hospice on these 
dates of service. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 6, 2021. The enrollee was under the Medicare hospice 
benefit for the date of service May 27, 2021 at issue in this appeal. Also, date of service June 8, 2021 was 
provided before the end of the month of June 2021. Therefore, we decided that the Plan does not have to pay 
for surgical pathology services provided on May 27, 2021, and June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluorescein angiography and indocyanine-green angiography 
(92242) provided on September 14, 2021. 
 
You asked the Plan to pay for fluorescein angiography and indocyanine-green angiography. The Plan denied 
your request. The Plan says the Plan has insufficient documentation to corroborate the services so the Plan 
cannot confirm Medicare coverage has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of fluorescein angiography and 
indocyanine-green angiography have been met. Therefore, we decided that the Plan does not have to pay for 
fluorescein angiography and indocyanine-green angiography (92242) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on November 23, 2021, 
under your medical benefits. 
 
You asked the Plan to pay for the Shingles vaccine. You say that no one told you this vaccine would not be 
covered in the office. The Plan denied your request. The Plan says the Shingles vaccine is not covered under 
your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine you received on 
November 23, 2021, under your medical benefits.  
 
Benefits for the Shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on October 21, 2021. 
 
You asked the Plan to pay for eyewear. You say that you have a PPO Plan, and it should not matter if the 
provider is not in-network. The Plan denied your request. The Plan says the services are a covered benefit; 
however, it is only covered when received from a Plan Vision network provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a Plan Vision network provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear was not purchased from a Plan 
Vision network provider. Based on this information, we decided that the Plan's rules for coverage of eyewear 
have not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on  
October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing provided on July 14, 2021, billed with code 76377. 
 
You asked the Plan to pay for 3D rendering with interpretation and reporting of advanced imaging. You say 
that this should be paid. The Plan denied your request. The Plan says there was no billed imaging procedure 
related to this service in the claims history. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 76376 and 76377 must be performed in 
conjunction with the base imaging procedure. 
 
The documentation does not support that this code was billed with a base imaging procedure. Therefore, we 
decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing provided on July 14, 2021, billed with code 76377.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable ventilator (E0466). 
 
You asked the Plan to pre-approve portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD as 
well as severe obesity and obesity-hypoventilation syndrome. Also, possible OSA. A single ABG on 12/21/21 
showed CO2 retention with PaCO2 of 59.5, but circumstances of testing were not provided. You have been 
previously prescribed bipap with a backup rate, but the compliance report from 3/29 - 4/27/22 shows little use. 
The device was used at least 4 hrs on only 2 days (10%). This is not enough use to determine benefit, although 
you reported no subjective benefit. There is no ABG the day after bipap use, or overnight oximetry on bipap 
and oxygen, to document bipap failure. Bipap with AVAPS has not been tried. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for vision hardware provided by 
on January 17, 2022. 
 
You asked the Plan to reimburse you an additional amount for vision hardware. The Plan denied your request. 
The Plan says the maximum allowed for vision hardware is $200.00 for non-Medicare covered vision 
hardware. The member was reimbursed the maximum amount of $200.00 on January 26, 2022. 
 
The Plan contract covers a supplemental Pick Your Perks reimbursement program. This benefit covers non-
Medicare covered vision hardware. Eyeglasses and contact lenses are covered up to a maximum annual amount 
of $200. 
 
We looked at the file and the Plans rules. The file shows that the Plan has reimbursed you the maximum 
benefit amount of $200. Therefore, we decided that the Plan does not have to reimburse you an additional 
amount for vision hardware provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing related to end-stage renal disease (ESRD) 
provided on September 15, 2021. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that this should be separately payable. The 
Plan denied your request. The Plan says the lab must billed the ESRD facility for the lab services. 
 
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 
laboratory testing related to end-stage renal disease (ESRD) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on November 9, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON dermatology services. You say that you believe that no authorization is 
required for the first 5 visits. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered under the enrollee's specific plan. 
 
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 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 dermatology services provided on November 9, 2021 by an out-
of-network (OON) provider.