Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on February 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this was 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 an office visit (99214) provided on February 28, 
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 reimbursement of glasses received on January 23, 2022. 
 
You asked the Plan to pay for the glasses. You say that the Evidence of Coverage says that you should receive 
$250 towards the cost of these glasses. The Plan denied your request. The Plan says the maximum amount for 
this benefit has been paid.  
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 coversglasses up to $250 every year for non-Medicare covered prescription eyewear.. 
 
We looked at the file and the Plan's rules. The file shows that the maximum benefit for these services has 
already been paid in this calendar year. Based on this information, we decided that the Plan's rules for coverage 
of the glasses have not been met. Therefore, we decided that the Plan does not have to pay for reimbursement 
of glasses received on January 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit and testing to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve office visit and testing to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
office visit and testing to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the health club membership purchased on January 1, 
2021. 
 
You asked the Plan to reimburse these services. You say that the request for 2019 was processed to 2020. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses up to 
$250 per calendar year towards cost for membership in a qualified health club or fitness facility. 
 
Review of the file shows that you were reimbursed the full $250 for your health club membership for 2021. 
The Plan confirmed that your health club membership reimbursements were correctly processed from 2017 to 
2021. Therefore, we decided that the Plan does not have to reimburse the health club membership purchased on 
January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that you instructed the office staff to obtain 
authorization for this visit. The services were rendered in good faith assuming authorization was granted. The 
Plan denied your request. The Plan says there was no authorization obtained for the OON care. This was not an 
emergency visit, and network providers are available. 
 
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 the office visit provided on November 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
January 20, 2022, through January 28, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $325 per day, for days 1-6 and a $0 copayment per day, for days 7-90, for in-network inpatient 
hospital care.  
 
The enrollee has been asked to pay $1,950 ($325 copayment x 6 days) for the in-network inpatient hospital care 
provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care 
provided from January 20, 2022, through January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam (92014) provided on February 23, 2022. 
 
You asked the Plan to pay for the eye exam. You say that on the day of the appointment, the enrollee was 
advised that there would be a $0 copay for their diabetic eye exam. You also say that you feel this exam was 
coded incorrectly, and the enrollee should not have to pay this copay. The Plan denied your request. The Plan 
says that this claim processed correctly. The Plan also says that this visit did not have a diagnosis of diabetes. 
 
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. The Plan did not provide medical records for this case. Without this information 
we cannot determine what type of eye exam the enrollee received. Consequently, the Plan has not substantiated 
their denial of payment in this case. Therefore, we decided that the Plan has to pay for the eye exam (92014) 
provided on February 23, 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 waive the copayment for an external electrocardiographic (EKG) 
recording provided on March 7, 2022. 
 
You asked the Plan to waive the copayment for the external EKG recording. You say that the device came off 
and you did not know how to reattach it. You say that you were only able to wear the device for less than 24 
hours. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $25 
copayment for outpatient diagnostic procedures and tests.  
 
You have been asked to pay a $25 copayment for the external EKG recording. The external EKG 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. 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 an external electrocardiographic (EKG) recording provided 
on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you believe the lab services should 
be included in the facility charges. The Plan denied your request. The Plan says the cost-share was 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 $5 
copayment for each Medicare-covered lab service.  
 
You have been asked to pay a $5 copayment for lab services. Lab services 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 lab testing provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services and X-rays of the chest 
provided from January 18, 2022, to February 1, 2022. 
 
You asked the Plan to waive the copayments for the lab services and X-rays. You say that you feel like you 
have been surprise billed. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day, per provider, for lab services and a $35 copayment per day, per provider, for X-ray 
services.  
 
You have been asked to pay a $10 copayment for the lab services and a $35 copayment for each of the two X-
rays. The total for all services is $80. The lab services and X-rays fall 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 copayments 
for laboratory services and X-rays of the chest provided from January 18, 2022, to February 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scan of extracranial arteries. 
 
You asked the Plan to pre-approve duplex scan of extracranial arteries. 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 non-invasive extracranial arterial studies will be 
considered medically reasonable and necessary under certain circumstances. 
 
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 duplex scan of extracranial arteries. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
enrollee is asymptomatic and does not have any of the conditions or findings to support medical necessity and 
approval of the request per the CMS guideline. The review has determined that the enrollee did not meet the 
coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve duplex scan of extracranial arteries.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, in-situ hybridization cytopathology, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (22630) provided June 17, 2021 to June 24, 
2021. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does 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. 
 
We find that CPT code 22630 is not supported in the medical record. Specifically, a required device code was 
not billed along with the procedure. 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 (22630) provided June 17, 2021 to June 24, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on January 6, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the claim was filed within the 120-day deadline. You also 
say that this should be reprocessed and paid. 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 chest x-ray (71045) provided on January 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
May 18, 2021. 
 
You asked the Plan to waive the copayment for the EKG. You say that you did not have any tests that day. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for diagnostic tests.  
 
The records show that an EKG was performed on May 18, 2021. Therefore, you have been asked to pay a $10 
copayment for the EKG. The EKG 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 an electrocardiogram 
(EKG) provided on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuro-diagnostic monitoring services billed with codes 
95927-TC, 95937-TC, 95939-TC and 95938-TC provided on February 10, 2022. 
 
You asked the Plan to pay for the neuro-diagnostic monitoring services billed. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services were 
processed correctly according to Medicare billing 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. The rules say that all items and non-physician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of 
whether they are subject to PPS. 
 
We looked at the file and Medicare rules. The record shows that codes 95927, 95937, 95939 and 95938 were 
each billed with the TC modifier. The technical component of these codes is included in the payment to the 
facility. Therefore,  no separate payment will be made for the services as billed. Based on this information, we 
decided that Medicare rules for coverage of the neuro-diagnostic monitoring services billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the neuro-diagnostic monitoring services billed 
with codes 95927-TC, 95937-TC, 95939-TC and 95938-TC provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 1, 
2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided to the 
patient for use during surgery. The Plan denied your request. The Plan says pneumatic compression devices are 
not covered to prevent deep vein thrombosis following surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
for the treatment of lymphedema or for chronic venous insufficiency with ulceration.  Pneumatic compression 
devices are not covered for the prevention of thromboembolism. The pneumatic compression device you 
provided was for the express purpose of thromboembolism prevention during surgery. Neither Medicare nor 
the Plan covers pneumatic compression devices for this purpose. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427) and ground mileage (A0425) provided on July 9, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 1, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
advanced life support, emergency transport (A0427) and ground mileage (A0425) provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76705 and 93976 billed for date of service 
January 27, 2022. 
 You asked the Plan to pay for procedure code 76705 and 93976. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for codes 76705 and 93976 is 
bundled into payment for codes 93976 and 76857. 
 
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 codes 
76705 and 93976 are column II codes to column I codes 93976 and 76857. 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 codes 76705 and 93976 billed 
for date of service January 27, 2022.