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

 
We decided that the Plan does not have to pay for frames (V2020), photochromatic tint (V2744), anti-reflective 
coating (V2750) progressive lenses (V2781) and polycarbonate lenses (V2784) provided on October 3, 2022.  
You asked the Plan to pay for frames (V2020), photochromatic tint (V2744), anti-reflective coating (V2750) 
progressive lenses (V2781) and polycarbonate lenses (V2784). You say that you believe the Plan should pay 
the $200. The Plan denied your request. The Plan says there is no coverage if glasses or related services are 
received from an out-of-network provider. 
 
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 all eyewear is purchased from a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for all eyewear costs not 
purchased from a Plan vision network provider. The record shows this eyewear was not purchased in-network. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020), photochromatic tint 
(V2744), anti-reflective coating (V2750) progressive lenses (V2781) and polycarbonate lenses (V2784) have 
not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), photochromatic tint 
(V2744), anti-reflective coating (V2750) progressive lenses (V2781) and polycarbonate lenses (V2784) 
provided on October 3, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance ground mileage provided on August 5, 2022. 
 
You asked the Plan to pay for the ambulance ground mileage. You say that you are requesting a reconsideration 
for the service provided twice on the same day of service. The Plan denied your request. The Plan says that this 
is a duplicate claim that has already been considered for payment. 
 
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 hasnt shown the denial reason is correct and havent 
offered any other reason to support a denial for this service. Therefore, we decided that the Plan has to pay for 
ambulance ground mileage provided on August 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a DyAnsys electro-acupuncture 
peripheral nerve device (64555 and L8679). 
 
You asked the Plan to pre-approve the implantation of a DyAnsys electro-acupuncture peripheral nerve device. 
You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the implantation of a DyAnsys electro-acupuncture peripheral nerve device have not been met. 
Specifically, this service is for a auricular electrical device which is not covered. Therefore, we decided that the 
Plan does not have to pre-approve the implantation of a DyAnsys electro-acupuncture peripheral nerve device 
(64555 and L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on November 16, 2021, to November 11, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $4,190.15. 
The amount you are being asked to pay $838.03 ($4,190.15 x 20% = $838.03). This item/service falls within 
the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on November 16, 2021, to November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on September 2, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you disagree with the 
copayment. 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 $45 
copayment for urgently needed services.  
 
You have been asked to pay a $45 copayment for urgent care visit. This item/service falls within the urgently 
needed 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. Therefore, we decided that the Plan does not have to waive the copayment for urgent care visit provided 
on September 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation provided on August 15, 2022. 
 
You asked the Plan to pay for the routine transportation. You say that you needed to go to an appointment for a 
computed tomography (CT) scan. You also say that the rehabilitation facility informed you to use this service 
to take you to your appointment. The Plan denied your request. The Plan says the service was not provided by 
the Plan's designated provider. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when this benefit is only available through the Plan's designated 
provider.  
 
We looked at your request, the records in the case file, and the rules. This transportation was not provided by 
the Plans designated provider. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for routine 
transportation provided on August 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is deconditioned and needs repetitive exercise and ambulation as 
tolerated. The enrollee does not require intensive therapy nor does the enrollee have medical barriers to 
rehabilitation course requiring frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0230, D0350 and D1330) on August 9, 
2022. 
 
You asked the Plan to pay for the dental services (D0230, D0350 and D1330). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
requested dental service (D0230) has already been exhausted. Additionally, the dental services (D0350 and 
D1330) are not covered services. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 3, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0230, D0350 and D1330) on 
August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on January 25, 
2022, to January 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF visit. You say that the records attached support the services provided. The 
Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 items/services at issue in this appeal. 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 a skilled nursing facility (SNF) visit provided on 
January 25, 2022, to January 27, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care visit (99291) provided on April 27, 2022. 
 
You asked the Plan to pay for the critical care service. You say that the service is not related to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the critical care visit (99291) provided on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for admission 
to an LTACH. 
 
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 pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has ongoing acute medical issues from antibiotic induced neurotoxicity 
and acute kidney injury and still requires acute care services. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. The Plan has 
approved ongoing care in the current acute care setting. 
 
 
 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 pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93005) provided on October 27, 
2021. 
 
You asked the Plan to pay for the electrocardiogram. You say that the submitted NPI was valid, and you would 
like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the provider did not 
bill as required by Medicare coding regulations. 
 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 93005 is Electrocardiogram, routine ECG with at least 12 
leads; tracing only, without interpretation and report. 
 
We find that CPT code 93005 is not supported in the medical record. Specifically, the provider's National 
Provider Identifier (NPI) is missing. Based on this information, we decided that Medicare rules for coverage of 
the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (93005) provided on October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear imaging test provided on 
October 12, 2022. 
 
You asked the Plan to waive the copayment for the nuclear imaging test. You say that you were unaware that 
there is a copayment for this service. 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 $175 
copayment for each in-network Medicare-covered diagnostic imaging service.   
 
You have been asked to pay a $175 copayment for the nuclear imaging test. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the nuclear imaging test provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient lift, a semi-electric hospital bed and a wheelchair 
provided from July 26, 2022, to August 26, 2022, by an OON provider. 
 
You asked the Plan to pay for a patient lift, a semi-electric hospital bed and a wheelchair. You say that you are 
appealing this denial. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
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 items/services at issue in this appeal. 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 a patient lift, a semi-electric hospital bed and a 
wheelchair provided from July 26, 2022, to August 26, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 6, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 6, 
2022, to June 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $285 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $285 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay $570 ($285 x 2days = $570). This item/service falls within the inpatient 
hospital 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 inpatient hospital care 
provided on June 6, 2022, to June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78070 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 78070. You say that the records support the procedure was 
performed. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78070 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 78070 billed for date of 
service October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug coded J3490 provided on June 9, 2022. 
 
You asked the Plan to pay for the unclassified drug. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as surgery procedure 20552 (injection(s); single or multiple trigger point(s), 1 or 2 
muscle(s)). This means this code was billed within the global surgical period of the surgery procedure without 
an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the 
unclassified drug have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drug coded J3490 provided on June 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on July 07, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. 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 a nursing facility visit 
provided on July 07, 2022.