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

 
We decided that the Plan has to make payment for the hearing aids provided on September 8, 2021. 
 
You asked the Plan to make payment for the hearing aids. You say that these hearing aids were provided after a 
hearing exam and should be covered by the Plan. The Plan denied your request. The Plan says that there was no 
proof of delivery to the enrollee. As such, payment cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers must maintain proof of delivery for 
equipment rendered to enrollees. 
 
We looked at the file and Medicare rules. The provider submitted a form signed by the enrollee indicating that 
the hearing aids were received on the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the hearing aids have been met. Therefore, we decided that the Plan has to make 
payment for the hearing aids provided on September 8, 2021.  
 
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 for an eye refraction procedure (92015) provided on February 3, 
2022. 
 You asked the Plan to pay for an eye refraction. You say that the service at issue was a diabetic exam rather 
than a routine exam. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 provided during a routine exam by a contracted routine vision 
care provider. 
 
We looked at the file and the Plan's rules. In this case, an eye refraction was provided during a non-routine 
exam related to a diagnosis of diabetes. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction procedure (92015) provided on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (43499) provided January 11, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were 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 43499 is not supported in the medical record. Specifically, a Not-Otherwise-Specified 
code was billed without a complete procedure description. Based on this information, we decided that Medicare 
rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient services (43499) provided January 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110, 97149, G0283) provided 
on January 21, 2022, to January 24, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that some International Classification of Diseases, 
10th Revision, Clinical Modification (ICD-10-CM) codes indicate laterality, specifying whether the condition 
occurs on the left, right or is bilateral.  
 
 
 
 
 We looked at the file and Medicare rules. The services at issue were billed with unilateral diagnosis codes for 
both sides of the body (G56.01, G56.01, M25.531, and M25.532) rather than the more appropriate bilateral 
codes. Based on this information, we decided that Medicare rules for coverage of physical therapy services 
have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services 
(97110, 97149, G0283) provided on January 21, 2022, to January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and related services 
(71046, 87636, C9803) provided on November 29, 2021. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and related services. You say that you have 
provided records to support the service billed. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier 25 reported with an E&M code, status 
indicator V, is used to report a medical visit that takes place on the same date that a procedure with status 
indicator S or T is performed, but that is significant and separately identifiable from the procedure. 
 
We looked at the file and Medicare rules. The case record documents that procedure code 71046 was billed 
with code G0463. Modifier 25 is therefore required on code G0463. Based on this information, we decided that 
Medicare rules for coverage of a hospital outpatient clinic visit and related services have not been met. 
Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and 
related services (71046, 87636, C9803) provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a handrail. 
 
You asked the Plan to pre-approve a handrail. You say that you have Parkinsons disease, and you need the 
handrail so that you do not fall going up or down the stairs. The Plan denied your request. The Plan says the 
requested item is not covered as durable medical equipment as it is not primarily medical in nature and is useful 
in the absence of illness or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a handrail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on January 13, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that your doctor recommended this vaccine and 
did not tell you it was not covered. You said that had you known the cost, you would not have gotten it. The 
Plan denied your request. The Plan says the Shingles vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine you received on 
January 13, 2022.  
 
Benefits for the Shingles vaccine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided January 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the test was not ordered by the enrollee's primary physician. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. There is no record of the test being ordered by the treating physician. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve the PT services. You say that the enrollee would benefit from further PT. 
The Plan denied your request. The Plan says additional PT services exceed the enrollee's medical need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. The patient has 
had prior therapy and the documentation does not reveal that the patient requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist or under the supervision of a therapist. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. The patient is ambulating 120 feet without an assistive device. She has been instructed in 
a home exercise program. Ongoing skilled therapy is not medically 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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy (PT) sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on December 2, 2021. 
 
You asked the Plan to pay for the back brace. You say that you have provided sufficient documentation for this 
claim to be paid. The Plan denied your request. The Plan says equipment provided as a result of phone 
solicitation is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the back brace have 
not been met. Therefore, we decided that the Plan does not have to pay for the back brace provided on 
December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Microbiology Procedures, Infectious Agent Antigen 
Detection (87633) provided on November 16, 2021. 
 
You asked the Plan to pay for Microbiology Procedures, Infectious Agent Antigen Detection. The Plan denied 
your request. The Plan says Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that Panels with >5 respiratory pathogens performed in 
the Part B outpatient setting are considered not medically reasonable and necessary 
 
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 pay for Microbiology Procedures, Infectious Agent 
Antigen Detection. Our reviewer says that the Microbiology Procedures, Infectious Agent Antigen Detection 
are not medically reasonable and necessary. Our physician reviewer found that the record indicates that a test 
panel has been ordered that contains more than 5 respiratory pathogen targets. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Microbiology Procedures, Infectious Agent Antigen Detection have not been 
met. Therefore, we decided that the Plan does not have to pay for Microbiology Procedures, Infectious Agent 
Antigen Detection (87633) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99231) provided on January 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 99231 
is a column II code to column I code 99233. 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 the services (99231) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) provided December 7, 
2021. 
 
You asked the Plan to pay for the office visit. You say that these services were always paid before and the Plan 
should cover this type of provider. The Plan denied your request. The Plan says if you go to a provider who is 
not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99215) 
provided December 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over the counter, home COVID testing kits purchased 
January 11, 2022. 
 
You asked the Plan to pay for the home testing kits. You say that if you went to a doctor to have the test done, 
it would have been covered. The home testing should be covered since it is the same service at less the costs. 
The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the home 
testing kits is an OTC item. Therefore, we decided that the Plan does not have to pay for over the counter, 
home COVID testing kits purchased January 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the scrotum and contents (76870) provided 
on September 14, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this claim was denied in error. The Plan denied your 
request. The Plan says there is a separate claim for this date and service provided for this enrollee which has 
been paid. No medical records were provided to support that the enrollee had this service twice on the date in 
question. 
 
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 ultrasound of the scrotum and 
contents (76870) provided on September 14, 2021. have been met. Specifically, medical records were not 
provided to support this service as billed. Therefore, we decided that the Plan does not have to pay for the 
ultrasound of the scrotum and contents (76870) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 27, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this is not a new patient to the provider and service was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and 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 August 27, 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 ophthalmology services provided on November 23, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ophthalmology services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 ophthalmology services provided on November 
23, 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 the anesthesia (CPT code 01480-AA-QS-P3) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The rules say that only the anesthesia service which has the highest base unit value should be reported. Per 
Review of claims history shows referring CPT code 01916 has the highest base unit value and was billed and paid under the claim for the date of service January 6, 2022. Therefore, we decided that the Plan does not have 
to pay for the anesthesia (CPT code 01480-AA-QS-P3) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve acupuncture treatment. The Plan denied your request. The Plan says the 
guidelines for coverage of acupuncture treatment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 acupuncture treatment have been met. 
You have not provided the medical documentation to corroborate and confirm that Medicare criteria have been 
met. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on November 
14, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that this ambulance transport 
was medically necessary. The Plan denied your request. The Plan says this transport was not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the non-emergency ambulance services. Our 
reviewer says that these ambulance services were not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this patient. The documentation did not support 
that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. T 
 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 non-emergency ambulance services have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance services provided on November 14, 
2021.