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

 
We decided that the Plan does not have to pay for the Cognizin Citicholine purchased on April 1, 2022. 
 
You asked the Plan to pay for the Cognizin Citicholine. You say that you understand that Cognizin Citicholine 
is not currently under the Plan's OTC reimbursement program, but you would like the Plan to consider adding 
it. The Plan denied your request. The Plan says Cognizin Citicholine is not an eligible item on the Plan's 
reimbursable over-the-counter benefit list. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, your 
plan offers a supplemental benefit for specific OTC items. Cognizin Citicholine is not listed as a covered OTC 
benefit under the supplemental reimbursement program. Therefore, we decided that the Plan does not have to 
pay for the Cognizin Citicholine purchased on April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair, complex, trunk; 2.6 cm to 7.5 cm provided to the 
enrollee on December 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 this is not reimbursable as a separate 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. 
 
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 that the operative report describes 
autologous fat harvested, and area closed. In this case, the closure would be inclusive to the harvested fat procedure. Modifier -59 cannot be verified. 
 
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 repair, complex, trunk; 2.6 cm to 7.5 cm provided to the enrollee on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear warranty (V2797) purchased on November 12, 
2022. 
 
You asked the Plan to pay for the eyewear warranty. You say that this should have been covered under your 
vision benefit. The Plan denied your request. The Plan says this service is not covered by 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 routine eye wear such as glasses (lenses and frames) or contact lenses in lieu of 
glasses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you purchased a warranty for your 
eyewear, which is not covered under your routine eye wear benefit. Based on this information, we decided that 
the Plan's rules for coverage of the eyewear warranty have not been met. Therefore, we decided that the Plan 
does not have to pay for the eyewear warranty (V2797) purchased on November 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on March 16, 2022. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
March 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network, non emergent ambulance 
ride provided on November 02, 2022. 
 
You asked the Plan to waive the copayment for an in-network, non emergent ambulance ride. You say that you 
did not take the ambulance, your spouse took you to the hospital. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an in-network, non emergent ambulance ride. This 
item/service falls within the ambulance services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. You were still seen by the emergency medical staff who came 
with the ambulance, and called the ambulance. Therefore, the copayment is upheld. Therefore, we decided that the Plan does not have to waive the copayment for an in-network, non emergent ambulance ride provided on 
November 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 31, 2022, to 
September 19, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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, we find that 
the first Q code line and first G code line were not billed with the same revenue code. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from August 31, 2022, to September 
19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) provided to 
the enrollee from September 25, 2022, to September 26, 2022. 
 
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 Current Procedural Terminology (CPT) code 99233 (1 unit) remains not supported. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 that the records do not show any 
medical decision making of high complexity to support this billed evaluation and management code. The 
review has determined that the records did not support that CPT 99233 was rendered in this case. The records 
did not support a detailed interval history and examination. 
 
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 subsequent hospital care (procedure code 99233) provided to the enrollee from September 25, 
2022, to September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory service provided on October 11, 
2022. 
 
You asked the Plan to waive the copayment for laboratory service. You say that you pay your copayments 
upfront, so you do not understand why you keep receiving bills. Also, you do not understand why the Plan does 
not cover lab fees. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for laboratory tests. 
 
You have been asked to pay a $10 copayment for laboratory service. This item/service falls within the 
laboratory tests 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 laboratory service provided 
on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye refraction (92015) provided on November 11, 
2022. 
 You asked the Plan to pre-approve an eye refraction (92015). You say that you cannot afford to pay for a 
refraction upfront. The Plan denied your request. The Plan says eye refractions are only covered by your plan if 
performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refractions are performed during a routine eye 
examination. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover an eye refraction during a routine 
examination.  The record shows this was not a routine eye examination. Based on this information, we decided 
that the Plan's rules for coverage of an eye refraction (92015) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an eye refraction (92015) provided on November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided by an in-network 
provider on September 1, 2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that you think that these services 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that until your $450 in-network deductible is paid, you must pay the full cost for 
covered in-network services, and your in-network deductible applies to the in-network lab services. 
 
You have been asked to pay a $209.57 deductible for the lab services ($9.51 + $36.85 + $52.80 + $13.96 + 
$86.42 + $10.03 = $209.57). The items or services you asked the Plan to waive the deductible for fall within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $450 in-network deductible which applies to 
outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation 
that had not been met at the time the lab services were received on September 1, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for the lab services provided by an in-network provider on 
September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the progressive lenses, photochromatic 
lenses, and the anti-reflective coating provided on August 31, 2022. 
 You asked the Plan to pay for the vision services. You say that you have never had to pay for eyewear in the 
past and believes the services should be covered. The Plan denied your request. The Plan says the services are 
not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you receive routine eyewear or contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are not considered routine services. Based 
on this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for the deluxe frames, the progressive lenses, 
photochromatic lenses, and the anti-reflective coating provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 10, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility services provided on November 11, 2022. 
 
You asked the Plan to pay for nursing facility services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility services 
provided on November 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intravenous infusions (96365) provided 
from July 1, 2022, to July 31, 2022. 
 
You asked the Plan to waive the copayment for the intravenous infusions. You say that you do not have the 
ability to pay for these services, and were under the impression that the Plan would cover the service. You also 
say that each time you went for your antibiotic infusion, you were told it was paid for by your insurance. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay up to an 
in-network maximum out-of-pocket amount of $6,700 for the 2022 plan year.  
 
 
 At the time this claim was processed, only $1,193.66 of the $6,700 in-network maximum out-of-pocket amount 
had been met. This resulted in a total copayment amount of $5,506.34 because this amount, along with other 
cost sharing amounts you have been asked to pay, met the $6,700 in-network maximum out-of-pocket amount 
for 2022. 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 intravenous infusions (96365) provided 
from July 1, 2022, to July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 18, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 proof of delivery 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 the durable medical equipment provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network heart procedure provided on 
September 12, 2022. 
 
You asked the Plan to waive the cost for an in-network heart procedure. You say that you were in the recovery 
room then left. The Plan denied your request. The Plan says this cost sharing was charged correctly. This 
charge is for the procedure, not the recovery room. 
 
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 $450 
deductible, and 10% coinsurance for Medicare-covered outpatient hospital facility visit. 
The allowed amount of this procedure was $7,892.92 resulting in a 10% coinsurance of $789.29. You are being 
asked to pay the lower amount of $763.80. There was a $254.96 charge towards your deductible ($254.96 + 
$763.80 = $1,018.76).  
 
You have been asked to pay a $1,018.76 combined cost for Medicare-covered outpatient hospital facility visit 
for an in-network heart procedure.  This item/service falls within the Medicare-covered outpatient hospital facility visit 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 for an in-network heart procedure provided on September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open sacral iliac joint fusion procedure. 
 
You asked the Plan to pre-approve an open sacral iliac joint fusion procedure. 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 an open sacral iliac joint fusion 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
open sacral iliac joint fusion procedure, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an open sacral iliac joint fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an open sacral iliac joint fusion procedure.