Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 8, 
2022, to May 4, 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 the Notice of Admission (NOA) is required to process claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The NOA 
is required documentation for this case. The provider did not send this to the plan or to MAXIMUS.. Therefore, 
we decided that the Plan does not have to pay for home health services provided to the enrollee from April 8, 
2022, to May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating lenses (V2750), frames (V2020), 
sphere, single vision lenses (V2100), polycarbonate lenses (V2784), photochromatic tint (V2744), and vision 
supplies, or accessories (V2797) provided on July 15, 2022. 
 
You asked the Plan to pay for anti-reflective coating lenses (V2750), frames (V2020), sphere, single vision 
lenses (V2100), polycarbonate lenses (V2784), photochromatic tint (V2744), and vision supplies or accessories 
(V2797). You say that without your eye doctor's help, you will probably end up blind. You also say you have 
diabetes, and it is getting pretty bad. The Plan denied your request. The Plan says the member's $175 
eyeglasses benefit applied correctly in accordance with the member's 2022 EOC. The Plan also says that after 
the $175 benefit was the applied, that left the member responsible for the rest. The Plan also says that the 
vision supplies, or accessories (V2797) is not listed as a covered service under the supplemental vision 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 a $175 allowance for eyeglasses and contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover a $175 allowance for eyeglasses and 
contact lenses every year. The rules also say that after the plan paid benefits for eyeglasses (lenses and frames), 
you are responsible for the remaining cost. The record shows the Plan paid their portion of the frames and 
lenses. Based on this information, we decided that the Plan's rules for coverage of anti-reflective coating lenses 
(V2750), frames (V2020), sphere, single vision lenses (V2100), polycarbonate lenses (V2784), a 
photochromatic tint (V2744), and vision supplies or accessories (V2797) have not been met. Therefore, we 
decided that the Plan does not have to pay for anti-reflective coating lenses (V2750), frames (V2020), sphere, 
single vision lenses (V2100), polycarbonate lenses (V2784), photochromatic tint (V2744), and vision supplies, 
or accessories (V2797) provided on July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy procedure provided on July 14, 2022, billed 
with codes 45382 and 45390. 
 
You asked the Plan to pay for the colonoscopy procedures as billed. You say that the records support the billed 
services. The Plan denied your request. The Plan says the two denied codes are not supported in the operative 
report. 
 
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 4538 is colonoscopy, flexible; with control of bleeding, 
any method. The definition of 45390 is colonoscopy, flexible; with endoscopic mucosal resection 
 
We find that these CPT codes are not supported in the medical record. Specifically, there is no documentation 
supporting that these two codes were distinct from the paid codes on this claim. The record shows that an 
injection was done, and two polyps were removed. The control of bleeding was directly related to the polyp removal. In addition, the mucosal resection is not shown to be separately identifiable as the only tissue 
removed was of the two polyps. Both of these codes are integral to procedure code 45385, which was paid on 
the claim. Based on this information, we decided that Medicare rules for coverage of the colonoscopy 
procedures as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
colonoscopy procedure provided on July 14, 2022, billed with codes 45382 and 45390.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the receiver (Monitor), dedicated, for use with therapeutic 
continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(K0553) provided March 3, 2022. 
 
You asked the Plan to pay for the CGM device and supplies. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says evidence of 
misrepresented services 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
indicated on the form and confirmed that the there is no order on file for the items for this enrollee. The Plan 
also made outreach to the enrollee and the enrollee informed the Plan that they do not have a therapeutic 
continuous glucose monitor. 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 receiver 
(Monitor), dedicated, for use with therapeutic continuous glucose monitor system (K0554) and supply 
allowance used with a therapeutic CGM device (K0553) provided March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on August 22, 2022, by an OON provider. 
 
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 x-rays provided on August 22, 2022, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lens (V2781) provided 
on July 13, 2022. 
 
You asked the Plan to pay for the eyewear. You say that it was your doctor's suggestion to get the transition 
lenses to protect your eyes and prevent you from having seizures due to sunlight. The Plan denied your request. 
The Plan says this second pair of eyewear exceeds the maximum benefit per period. 
 
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 eyewear once per year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid for the eyewear you purchased 
on May 17, 2022, and your routine vision services benefit has been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay for the frames (V2020) and progressive lens (V2781) provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on March 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on November 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. You say that this should be covered and was medically necessary. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 an ultrasound provided on November 8, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 03, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on February 03, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (procedure code 83789) provided to the enrollee 
on May 23, 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 this claim is billing for a not elsewhere classified code and does not state on the claim form a 
corresponding description for a non-specific procedure code. 
 
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 the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for lab services (procedure code 83789) provided to the enrollee on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on July 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
December 14, 2021. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.   
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services provided in this case were 
rendered by a licensed acupuncturist who was not under the supervision of a physician, physicians assistant, 
nurse practitioner, or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tube thoracostomy provided to the enrollee on April 6, 
2022. 
 
You asked the Plan to pay for the procedure. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes are not supported in the records submitted. 
 
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 32551 is "Tube thoracostomy, includes connection to 
drainage system (eg, water seal), when performed, open (separate procedure)." 
 
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 procedure. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the record indicates 
that the enrollee underwent operative procedures on April 6, 2022. The provided operative notes do not 
describe the performance of the billed service.  
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pay for a tube thoracostomy provided to the enrollee on April 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) provided on June 16, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that you went to live with your 
daughter. You say that you went to follow up with a family physician. You also say that this resulted in you 
going to the emergency room and staying for 3 weeks. 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 office visit (99205) provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visit provided on February 25, 2022. 
 
You asked the Plan to waive the cost share for office visit. You say that you are disputing the share cost. 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 10% 
coinsurance for physician/practitioner services, including doctor's office visits. The Plan says that you must pay 
$100 deductible for physician/practitioner services. The allowed amount of this service is $177.44. You have 
$18.33 out of $100 deductible, resulting in an amount of deductible $81.67 ($177.44  $81.67 = $95.77). Then 
the allowed remaining amount of this office visit total $95.77, resulting in a coinsurance amount of $9.58. 
 
You have been asked to pay 10% coinsurance for office visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 cost share for office visit provided on February 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on July 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that you should not be penalized for 
providing medically necessary services to the enrollee. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under the Plan unless they are pre-authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on 
July 22, 2022, by an out-of-network (OON) provider.