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

 
We decided that the Plan does not have to pay for the hearing aid and batteries provided on October 14, 2021. 
 
You asked the Plan to pay for the hearing aid and batteries. The Plan denied your request. The Plan says 
hearing aid batteries are not covered, and the $2,000 benefit has been paid. 
 
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 up to 
$2,000 for hearing aids every 3 years. 
 
 
  We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid and batteries have not been met. Specifically, hearing aid batteries are not a covered 
benefit. The Plan also paid $2,000 toward the hearing aid fitting and dispensing fee which exhausted the annual 
allowance. Therefore, we decided that the Plan does not have to pay for the hearing aid and batteries provided 
on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that the patient was a resident of a nursing home 
and the facility should have gotten authorization. The Plan denied your request. The Plan says unauthorized, 
non-plan care is not covered.  The patient was not in a covered nursing home stay on the date of service in 
question. 
 
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 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 podiatry services provided on January 25, 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 ambulance services provided on January 6, 2022. 
 
You asked the Plan to pay for ambulance services. You say that your wife was informed EMS should check 
you over and you should be taken to the emergency room. You say that you were scared of the emergency 
room and COVID-19. The Plan denied your request. The Plan says ambulance transportation is only covered 
when you are actually transported by ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for slings (A4565) provided on January 18, 2022. 
 
You asked the Plan to pay for slings. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says no payment is made for this service according to 
Medicare rules. 
 
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 looked at the file and Medicare rules. In this case, code A4565 has a Status Code of X under the Physician 
Fee Schedule indicating Statutory Exclusion. This means that no payment will be made under the physician fee 
schedule. This service is indicated as occurring incident to physician services that have already been paid. 
Based on this information, we decided that Medicare rules for coverage of slings have not been met. Therefore, 
we decided that the Plan does not have to pay for slings (A4565) provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you called an in-network 
provider and the machine you are requesting is on back order. They do not know when it will be available. The 
tank that you can get does not last long enough when you are out of the house. 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a portable oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on January 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory work. You say that the service was medically necessary. 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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for laboratory work 
provided on January 13, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on February 20, 2022, while 
traveling outside the country. 
 
You asked the Plan to pay for the COVID-19 test. You say that you would like this claim reprocessed and 
approved for payment as you feel this copayment for a COVID-19 is too high. The Plan denied your request. 
The Plan says there is no benefit for COVID-19 diagnostic tests when they are performed outside a laboratory, 
pharmacy, doctor, or hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that COVID-19 tests will not be covered for travel as 
they are not medically necessary. Based on this information, we decided that Medicare rules for coverage of the COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on February 20, 2022, while traveling outside the country.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer 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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and services provided on March 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and services. You say that you are requesting reconsideration of 
the claim. 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 
office visit and services. We found no exception that would require the Plan to pay for the office visit and 
services. The records provided for review do not show that the office visit and services were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the office visit and services provided on 
March 23, 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 subsequent hospital care (99232) provided on January 27, 
2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that this service was billed appropriately and 
is supported in the medical record. The Plan denied your request. The Plan says this service is included in the 
global surgery period for 32654 which was billed for this enrollee for date of service January 19, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, payment for CPT code 99232 is included in the 
global surgery package for CPT code 32654. Of note, CPT code 99232 has not been billed with the required 
modifier to indicate that this service would be separately payable. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for subsequent hospital care (99232) provided on January 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 8, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. 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 ambulance services provided on October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 the intracept 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 request for intracept intraosseous 
basivertebral nerve ablation at L2-3 and L3-4 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 the intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code 64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 February 20, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $26.01 copayment for the external electrocardiographic 
recording provided on December 15, 2021. 
 
You asked the Plan to waive the $26.01 copayment for the external electrocardiographic recording December 
15, 2021. You say that you were told that copayments would be waived for COVID-related procedures. The 
Plan denied your request. The Plan says your copayment has been applied 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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $26.01 copayment for an external electrocardiographic recording. An external 
electrocardiographic recording 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. Your contract with the Plan clearly says that you must pay a $45 copayment for in-
network, outpatient diagnostic tested provided in a specialists office. However, you have only been asked to 
pay $ 26.01, which is less than the $45 copayment amount. 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 
$26.01 copayment for the external electrocardiographic recording provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and ultrasounds provided on 
February 23, 2022. 
 
You asked the Plan to waive the copayments for an office visit and ultrasounds. You say that these copayments 
should be covered. The Plan denied your request. The Plan says the copayments applied are 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 $105 
copayment for radiological diagnostic services and $40 copayment for specialist office visit.  
 
 You have been asked to pay $145 copayment for an office visit and ultrasounds. Ultrasounds falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The office visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. Therefore, we 
decided that the Plan does not have to waive the copayments for an office visit and ultrasounds provided on 
February 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the office visit and related services received on January 
5, 2022, minus any cost share requirement. 
 
You asked the Plan to pay for the office visit and related services. You say that you would like the claims to be 
adjusted. The Plan denied your request. The Plan says that the submitted diagnosis code is not a covered 
benefit. 
 
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 provided the office visit and related services by a contract provider. The file does not show that the 
Plan provided notice that the office visit and related services would not be covered. Under Medicare rules, this 
means the office visit and related services is considered approved by the Plan. You are not responsible for the 
billing of specific diagnosis codes when services are received by a contract provider. Therefore, we decided 
that the Plan has to hold you harmless for the office visit and related services received on January 5, 2022, 
minus any cost share requirement.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camzyos. 
 
You asked the Plan to pre-approve Camzyos. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Camzyos.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the fundus photography. We decided that the Plan does not have to pay 
for the contact lens fitting.  
 
You asked the Plan to pay for vision services. You say that you were told you would not be responsible for 
these services. The Plan says that the contact lens fitting exceeds the frequency allowed by your eyewear 
benefit, and fundus photography is not covered by your supplemental vision benefit. 
 
We decided that the Plan has to pay for the fundus photography.  
 
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 has argued that fundus photography is not covered by your 
routine vision benefit, but has not explained why this service is not being processed and covered under your 
medical benefits. Fundus photography is a medical service. Therefore, we decided that the Plan has to pay for 
the fundus photography (92250) provided on March 18, 2022. 
 
We also decided that the Plan does not have to pay for the contact lens fitting. 
 
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 one pair of eyeglasses or contact lenses per year. 
 
We looked at the file and the Plan's rules. The record shows that you received routine eyeglasses on March 18, 
2022, which were covered by the Plan. You are covered for one pair of eyeglasses or one pair of contacts per 
year. Because you received eyeglasses and these were covered by the Plan, the contact lens fitting exceeded the 
limitations of your benefit. Based on this information, we decided that the Plan's rules for coverage of a contact 
lens fitting have not been met. Therefore, we decided that the Plan does not have to pay for the contact lens 
fitting (92310) provided on March 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.