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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5299) purchased on 
January 17, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider. 
 
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 they are rendered by an in-network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids were purchased from an out-of-
network provider. Coverage is provided for hearing aids only when purchased from an in-network provider. 
Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5299) 
purchased on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (38999) provided April 20, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 38999 is an unlisted procedure. 
 
We find that CPT code 38999 is not supported in the medical record. Specifically, the operative report did not 
describe in detail what the unlisted procedure performed was. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (38999) provided April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you received a routine eye exam 
from an in-network provider, and you should not have a copay for a routine eye exam. The Plan denied your 
request. The Plan says this claim was processed correctly. 
 
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. 
 
  We looked at the file and the Plan's rules. You are responsible for a $45 copay for each Medicare-covered eye 
exam to diagnose and treat diseases and conditions of the eye. The record shows that you received a medical 
eye exam for combined forms of age-related cataract and unspecified disorder of refraction. The exam you 
received was not routine. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the eye 
exam (92004) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on March 18, 2022. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not eligible to 
bill for assistant at surgery services per Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that you haven't seen the doctor in years. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment for Medicare-covered medical eye exam.  
 
You have been asked to pay $10 copayment for eye exam. Eye exams fall within the Vision Care 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 eye exam provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
November 2, 2020. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this visit was for a Botox 
injection and not a nerve block so you should only be charged $10. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for physician specialist services (including surgery second opinion, Medicare covered telehealth or 
urgently needed services). 
 
 
 
 You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 10, 2021, billed with 
codes 81225, 81230, 81238, 81240, 81241, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 10, 2021, billed with codes 81225, 81230, 81238, 81240, 81241, and 81291.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation and psychotherapy 
provided on March 2, 2022, to March 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and psychotherapy. You say that you 
looked up this therapist on the Plan website. The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 
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 
psychiatric diagnostic evaluation and psychotherapy. We found no exception that would require the Plan to pay 
for the psychiatric diagnostic evaluation and psychotherapy. Therefore, we decided that the Plan does not have 
to pay for the psychiatric diagnostic evaluation and psychotherapy provided on March 2, 2022, to March 31, 
2022, by an out-of-network (OON) provider.   
Your complaint about the Plan giving incorrect information is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 1, 2021, by an 
out-of-network (OON) provider. 
 You asked the Plan to pay for the services provided. You say that the enrollee meets coverage criteria by virtue 
of their risk. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on October 1, 2021, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lutathera. 
 
You asked the Plan to pre-approve Lutathera. You say that the requested Lutathera is medically necessary. The 
Plan denied your request. The Plan says the requested Lutathera is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Lutathera. Our reviewer says that the 
requested Lutathera is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of metastatic well differentiated carcinoid tumor of the small intestine, grade 3. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lutathera have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lutathera.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist office visit 
provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you thought the provider 
was in network. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $60 
copayment for each out of network Medicare covered specialist visit.  
 
You have been asked to pay $60 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 out of network specialist office visit provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided January 6, 2022. 
 
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 has not been met. 
 
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 85060 is not supported in the medical record. Specifically, code 85060 is  
used only when a physician interprets an abnormal peripheral blood smear for a hospital patient, and the 
hospital is responsible for the technical component. 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 (85060) provided January 6, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the insertion of intrauterine device (IUD) provided on April 18, 2022. 
 
You asked the Plan to pay for the IUD. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. 
 
You were referred for the IUD by a contract provider. The file does not show that the Plan provided notice that 
the IUD would not be covered. Under Medicare rules, this means the IUD is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the insertion of intrauterine device (IUD) provided on April 
18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. 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 February 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation hospital services (G0378) provided from July 
28, 2021, to August 3, 2021. 
 
You asked the Plan to pay for the observation hospital 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. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0378 is Hospital observation service, per hour. We find that CPT code G0378 is not supported in the medical record. Specifically, it is not appropriate to bill more than 
one line of observational services per claim. In this case multiple lines of CPT code G0378 have been billed. 
This does not meet Medicare guidelines for billing or reimbursement consideration. Based on this information, 
we decided that Medicare rules for coverage of the observation hospital services have not been met. Therefore, 
we decided that the Plan does not have to pay for the observation hospital services (G0378) provided from July 
28, 2021, to August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Suplena 1.8/CarbSteady. 
 
You asked the Plan to pre-approve Suplena 1.8/CarbSteady. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is covered for beneficiaries that meet 
specific criteria. 
 
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 Suplena 1.8/CarbSteady. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found as the enrollee does not intend 
to use this product as a tube feed and does not have permanent impairment of her gastrointestinal (GI) tract, it 
does not meet criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Suplena 1.8/CarbSteady have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Suplena 1.8/CarbSteady.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on February 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the enrollee has just moved to a different state 
and has a new primary care physician (PCP). You say the enrollee's information has been updated and therefore 
the claim should pay out. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 
telehealth visit. We found no exception that would require the Plan to pay for the telehealth visit. The records 
provided for review do not show that the telehealth visit was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the telehealth visit provided on February 21, 2022, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the claim processed as out-of-network in error with 
the facility national provider identifier (NPI) instead of the individual provider's NPI. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the office visit. The Plan did not pre-approve the office visit. 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 office visit provided on February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on March 16, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you believe you should be reimbursed for at least 
half the cost of these hearing aids because the facility you purchased them from is cheaper than the Plan's 
hearing aid vendor. The Plan denied your request. The Plan says this service was rendered by a non-
participating provider without prior authorization. 
 
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 they are purchased through a Plan approved hearing aid provider.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aids provided on March 16, 2022 by an out-of-network (OON) provider.