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

 
We decided that the Plan does not have to pay for hearing aids you purchased on October 19, 2021, from an 
out-of-network vendor. 
 
You asked the Plan to pay for the out-of-network hearing aids. You say that you would like the Plan to make an 
exception and cover these hearing aids. The Plan denied your request. The Plan says you did not obtain these 
hearing aids from a network vendor, so they are not covered. 
 
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 when purchased from the Plan's network hearing aid vendor.  You did not purchase these 
hearing aids from the Plan network hearing aid vendor. Therefore, we decided that the Plan does not have to 
pay for hearing aids you purchased on October 19, 2021, from an out-of-network vendor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425) provided August 4, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the units billed exceed the allowable amount.  
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 A0425 is 250. The MAI value for this code is 2. You billed 302 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services (A0425) provided August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair batter you purchased on June 16, 2021 from an 
out-of-network (OON) vendor. 
 
You asked the Plan to pay for the lift chair battery. You say that you paid out of pocket to get your lift chair 
back to a usable condition. The Plan denied your request. The Plan says items you get from an out-of-network 
provider are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lift chair batter you purchased on June 16, 
2021 from an out-of-network (OON) vendor.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgery services you received from a contracted hospital on October 
28, 2020. 
 
You asked the Plan to pay for the surgery services. You say that this was not a Worker's Compensation issue 
and this surgery was pre-approved. The Plan denied your request. The Plan says that you have a Worker's 
Compensation claim.  The Plan says that the hospital has not provided medical records to show that the surgery 
services were not work-related. 
 
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 claims that no medical records were provided showing that 
these services were not related to a Worker's Compensation issue.  You alleged that these services were NOT 
related to Worker's Compensation.  The hospital where you received these services is a contracted hospital with 
the Plan.  The Plan has not provided records from this Plan hospital to support their denial.  Since this is a Plan 
provider, these records are considered to be within the Plan's control and should have been submitted with the 
case file sent to us.  The Plan's failure to provide these records means that the Plan's denial is not supported. 
Therefore, we decided that the Plan has to pay for surgery services you received from a contracted hospital on 
October 28, 2020.  
 
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 laboratory services provided to the enrollee on July 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided August 30, 2021. 
 
You asked the Plan to pay for the sedation services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
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 code 99153 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a professional component / technical component indicator of 3 and is not separately 
payable for the place of service billed. Based on this information, we decided that Medicare rules for coverage 
of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99153) provided August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional catheter insertion services (procedure code 36561) 
provided to the enrollee on August 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is a duplicate charge. 
 
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 36561 is "Insertion of tunneled centrally inserted central 
venous access device, with subcutaneous port; age 5 years or older." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found denial as a duplicate service appears 
to be appropriate in this case. 
 
We looked at this coder'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 additional catheter insertion services (procedure code 36561) provided to the enrollee on 
August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a StabiLink MIS interspinous fixation device. 
 
You asked the Plan to pre-approve a StabiLink MIS interspinous fixation device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 pre-approve a StabiLink MIS interspinous fixation 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process distraction devices are experimental. 
More research is needed. 
 
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 StabiLink MIS interspinous fixation device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a StabiLink MIS interspinous fixation device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a modifier was not billed on the claim to represent the services as separate/distinct. 
 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 70544 
is a column II code to column I code 70551. 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 imaging services provided to the enrollee on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81210, 81235, 81275, 81276, 81295, 81298, 
81301, 81317, 81401, 81194, 81309) provided May 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
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 the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81210, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 
81401, 81194, 81309) provided May 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately.  
 
The services at issue in this case are for the purpose of specimen validity testing. 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 laboratory services provided to the enrollee on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 24, 2021, to April 22, 2021.  
You asked the Plan to pay for home health services. You say that this should be paid for. The Plan denied your 
request. The Plan says this must be paid at a reduced amount. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, RAPs need 
to be billed within 5 days of the start of services. The RAP was submitted on June 25, 2021.. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from March 24, 
2021, to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine received on December 1, 2021. 
 
You asked the Plan to pay for the services. You say that this was done at the physician's office. The Plan denied 
your request. The Plan says this might be covered under Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine received on December 1, 2021.  
 
Benefits for the services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided June 10, 
2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitness tracker you purchased on November 30, 2021. 
 
You asked the Plan to pay for the fitness tracker. You say that you were told that you qualified for the fitness 
reimbursement this year and that is how you got the reimbursement form. The Plan denied your request. The 
Plan says you exhausted your fitness tracker benefit when you purchased a fitness tracker on January 9, 2020. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan provides a benefit for 
fitness trackers only once every three years.  You already purchased a fitness tracker on January 10, 2020, so 
your benefit is exhausted. The Evidence of Coverage explicitly tells you that you were not eligible for coverage 
of the fitness tracker you purchased on November 30, 2021. Therefore, we decided that the Plan does not have 
to pay for the fitness tracker you purchased on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided September 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed is not separately payable. 
 
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 code 83789 is not supported in the medical record. Specifically, this CPT code is inclusive to 
CPT G0480 which was also billed and approved. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (83789) provided September 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided by a network facility on June 25, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you should not be responsible for 
the copayment amount because you were told the facility would refund $800. The Plan denied your request. 
The Plan says you have been asked to pay the correct cost-sharing amount. 
 
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 a $0 copayment per day for days 1-20 and a $140 copayment per day for days 21-100 at an in-
network Medicare-covered skilled nursing facility stay.  
 
The enrollee has been asked to pay a $324.18 copayment for the SNF stay. The SNF stay falls within the 
Skilled nursing facility (SNF) care benefit category. See chart below. 
 
Dates of Service Service SNF Days Copayment Day 
Count 
Member Liability 
June 2, 2021, to 
June 11, 2021 
SNF care 1-10 $0 10 $0 
June 16, 2021, to 
June 25, 2021 
SNF care 10-10 $0 10 $0 
June 25, 2021, to 
June 30, 2021 
SNF care 21-26 $140 4 $324.18  This is less 
than the standard 
amount because you 
reached your 
maximum out-of-
pocket amount. 
Total     $324.18 
 
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 the skilled nursing facility (SNF) stay provided 
by a network facility on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the compression stockings and glue you purchased from October 13, 
2021, to December 9, 2021. 
 
You asked the Plan to pay for the compression stockings and glue. You say that these stockings have been 
covered in the past and there is no reason for them to not be covered now. The Plan denied your request. The 
Plan says that compression stockings are generally not covered. 
 
The Plan must follow Medicare rules. That generally compression stockings are not covered under the durable 
medical equipment benefit.  However, compression stockings may be covered if used as a surgical dressing 
over an open venous stasis wound.  
 
In its denial, the Plan simply stated that compression stockings are not covered.  However, that is not true.  
There are clinical scenarios in which compression stockings can be covered.  The Plan has failed to provide any 
evidence that they have confirmed that you do not have a condition for which compression stockings may be 
covered.  The Plan has made no attempts to get medical records from their own contract providers (such as 
your primary care doctor) to determine if indeed compression stockings would be potentially coverable for you.  
The burden is on the Plan to provide that its denial is appropriate and to support that denial when submitting its 
case file to us for review.  The Plan has failed to do that. Therefore, we decided that the Plan has to pay for the 
compression stockings and glue you purchased from October 13, 2021, to December 9, 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 lab services (82310, 82728, 83540, 83550) provided October 
19, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. The lab services are included in payment for the ESRD services and 
are not separately payable. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82310, 
82728, 83540, 83550) provided October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0012M) provided September 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not 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 lab services (0012M) provided September 23, 2021. have been met. No clinical records were provided. The record was limited to lab results 
and medical literature only. Therefore, we decided that the Plan does not have to pay for lab services (0012M) 
provided September 23, 2021.