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

 
We decided that the Plan has to pay for the paring or cutting of benign hyperkeratotic lesion and office visit 
(11055, 99213) provided on February 9, 2022. 
 
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion and office visit. You say 
that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan 
says that the services denied correctly as prior authorization was not obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the paring or cutting of benign hyperkeratotic lesion and office visit by a contract 
provider. The file does not show that the Plan provided notice that the paring or cutting of benign 
hyperkeratotic lesion and office visit would not be covered. Under Medicare rules, this means the paring or 
cutting of benign hyperkeratotic lesion and office visit is considered approved by the Plan. Therefore, we 
decided that the Plan has to pay for the paring or cutting of benign hyperkeratotic lesion and office visit 
(11055, 99213) provided on February 9, 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 pay for wound care provided on March 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care. 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 wound care at issue in this appeal. The Plan did not pre-approve the 
wound care 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 wound care provided on March 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram (EKG) provided on January 22, 2020 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for electrocardiogram (EKG). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the appeal must be filed to the 
appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date 
the services were furnished. 
 
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 electrocardiogram (EKG) provided on January 22, 
2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non 
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The 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 January 20, 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 home services provided on October 4, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home services. You say that you provided medical records and are requesting 
payment for the service rendered to the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 home services provided on October 4, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on January 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The 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 subsequent hospital care provided on January 
10, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cane, cold pad with pump, and raised toilet seat (E0218, 
E0244, E0100) purchased on November 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cane, cold pad with pump, and raised toilet seat. You say that the items 
should be reimbursed. The Plan denied your request. The Plan says the denial applied correctly as the items 
were provided out-of-network and are not covered under the Plan's benefits. 
 
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 cane, cold pad with pump, and raised toilet seat 
(E0218, E0244, E0100) purchased on November 13, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2750, V2020, V2781) purchased on 
November 26, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you are unhappy that your vision benefits are 
separate from your medical benefits. The Plan denied your request. The Plan says Medicare only covers basic 
eyewear when it is provided following cataract surgery which includes removal of the lens of the eye. Medicare 
does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for 
refractive error only. Your Plan offers additional coverage for eyeglasses which are not covered by Medicare; 
however, this benefit requires services be received through the specified vendor network. 
 
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 they are received from an in-network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine vision 
vendor network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2750, V2020, 
V2781) purchased on November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on January 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The 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 subsequent hospital care (99233) provided on 
January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided by an out-of-
network provider on February 7, 2022, to February 14, 2022. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you would like the PLan to 
process this out-of-network. You say that you would pay less if it is processed as out-of-network. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
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 
copayment for chiropractic services/in-network.  
 
You have been asked to pay a $20 copayment for chiropractic services. These services have been processed 
correctly and paid accordingly. Chiropractic services falls within the chiropractic services/in-network 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 chiropractic services provided by an out-of-
network provider on February 7, 2022, to February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient visit provided on February 11, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient visit. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The 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 hospital outpatient visit provided on February 
11, 2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 13, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. 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 home health services provided on December 13, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you submitted documentation for review. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  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 January 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on August 9, 2021, to 
August 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 inpatient hospital stay provided on August 9, 
2021, to August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan of extremity veins (93971) provided on January 3, 
2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says that this claim was processed correctly. 
 
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 provided no argument and no citation or supporting 
evidence to show why this claim should not be paid. The Plans argument states only that, payment for this 
service was made according to the Medicare allowable rate; however, the documentation supports that no 
payment ($0.00) has been made for these services despite 93971 being a payable service. Therefore, we 
decided that the Plan has to reprocess this claim and pay for the duplex scan of extremity veins (93971) 
provided on January 3, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames (V2020), lens (V2200), polycarbonate or 
equal lens (V2784), and vision supply (V2797) provided on February 3, 2022. 
 You asked the Plan to pay more for the frames, lens, polycarbonate or equal lens, and vision supply. You say 
that you were only told there was a $100 discount. The Plan denied your request. The Plan says the total cost of 
the frames was $158.96, leaving $58.96 as your responsibility. The Plan also says that the additional $25 
accessory is not something covered by the 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 up to $100 toward the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. The record shows that your full benefit for the purchase and fitting of 
eyeglasses and pair of lenses was applied toward the claim for this date of service, and your $100 frames and 
lens package benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the frames, lens, polycarbonate or equal lens, and vision supply have not been met. Therefore, we 
decided that the Plan does not have to pay more for the frames (V2020), lens (V2200), polycarbonate or equal 
lens (V2784), and vision supply (V2797) provided on February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 14, 2022, 
and February 15, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that no one told you to bring your 
medications with you to the hospital that you take daily. The Plan denied your request. The Plan says it was 
confirmed that the medications you received were self-administered medications, and were denied as non-
covered correctly. 
 
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 pay for the self-administered drugs 
provided on February 14, 2022, and February 15, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022.