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

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you provided services to the enrollee and were 
unaware a referral and authorization was needed. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from the enrollee's primary care physician 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 August 30, 2021, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the routine eye exam (92014) and refraction (90215), provided on 
September 17, 2021. 
 
You asked the Plan to pay for the routine eye exam and refraction. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that you obtained these services through an out-of-
network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one exam a year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the routine eye exam and refraction have been met. Specifically, the Plan's EOC does not specify 
that you must use a network provider for the supplemental vision benefits. Therefore, we decided that the Plan 
has to pay for the routine eye exam (92014) and refraction (90215), provided on September 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), and harness 
(E2313). 
 
You asked the Plan to pre-approve the expandable controller and harness. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and harness. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the patient's upper extremity strength and function support that the patient can 
control any power options through their own switches. 
 
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 expandable controller and harness have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the expandable controller (E2377), and harness (E2313).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45378) provided on September 30, 2021. 
 
You asked the Plan to pay for the colonoscopy. You say that you were billed for this service which was free. 
You also say that you would like your money to be refunded to you. The Plan denied your request. The Plan 
says proof of this payment needs to be submitted to the Plan before the Plan can reprocess and submit the 
payment to you. 
 
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 colonoscopy (45378) provided on 
September 30, 2021 have been met. Specifically, no proof of payment was submitted. Therefore, we decided 
that the Plan does not have to pay for the colonoscopy (45378) provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for rib 
fracture and pelvic fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab work to be provided by an out-of-network (OON) 
provider for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there are network providers available to perform 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 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 
lab work to be provided by an out-of-network (OON) provider for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88291) provided on November 9, 2021. 
 
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 88291 
is a column II code to column I code G0452. 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 (88291) provided on November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram billed for services provided on August 
29, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim 
denied correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The record nor claim at issue shows a second interpretation due to 
questionable findings. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
billed for services provided on August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management of an individual (99397) provided on August 25, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management 
of an individual. You say that this treatment was medically necessary. The Plan denied your request. The Plan 
says determined that both the referring and attending providers are all non-participating with the Plan, and prior 
authorization was not obtained by the provider or facility. 
 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 periodic comprehensive preventive medicine 
reevaluation and management of an individual (99397) provided on August 25, 2021, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99601, 99602) provided on August 12, 2021, 
and August 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Codes 99601 and 99602 are assigned a status indicator of I under 
the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99601, 99602) provided on August 12, 2021, and August 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas device and vitamin injections (97016, 97032, 
97112, 96372, 99072, J1955, J3411, J3415, J3420, and J3490) provided from November 9, 2020, to December 
30, 2020. 
 
You asked the Plan to pay for the Sanexas device and vitamin injections. You say that you would like this 
claim to be reconsidered for coverage. The Plan denied your request. The Plan says this claim does not meet 
the guidance for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a NP or PA only when that NP/PA may perform physical therapy 
services under State law. Medicare rules also say that claims for compounded drugs shall be submitted using a 
compounded drug, NOC code. 
 We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical 
therapy in the State of Ohio. The multiple drug codes reported on this claim refer to a pre-filled compounded 
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified 
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are 
not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we 
decided that Medicare rules for coverage of the Sanexas device and vitamin injections have not been met. 
Therefore, we decided that the Plan does not have to pay for the Sanexas device and vitamin injections (97016, 
97032, 97112, 96372, 99072, J1955, J3411, J3415, J3420, and J3490) provided from November 9, 2020, to 
December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee arthroscopy and anesthesia services 
provided on October 6, 2021. 
 
You asked the Plan to waive the coinsurance for a knee arthroscopy and anesthesia services. You say that your 
insurance plan took no action to correctly place you in the correct coverage plan after being notified of 
Medicaid qualification changes. You also say that is the reason you have been paying so much out of pocket. 
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 20% 
coinsurance for in-network outpatient surgery at an outpatient hospital. The Plan contract also says that 
enrollees must pay 20% coinsurance for in-network part B drugs in all outpatient settings 
 
You have been asked to pay $501.44, which is 20% of the allowed amount for a knee arthroscopy ($2,507.22 
allowed amount x 20% coinsurance = $501.44). A knee arthroscopy falls within the Outpatient Surgery, 
Including Service Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. 
You have been asked to pay $31.43, which is 20% of the allowed amount for anesthesia services ($157.17 
allowed amount x 20% coinsurance = $31.43). You have been asked to pay a total of $532.87 ($501.44 
coinsurance + $31.43 coinsurance = $532.87). Anesthesia services fall within the Medicare Part B Prescription 
Drugs 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 coinsurance for a knee arthroscopy and 
anesthesia services provided on October 6, 2021.  
 
Your complaint about the Plan not notifying you of your Medicaid qualification changes is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of skin substitute graft (15271) provided on 
April 20, 2021. 
 
You asked the Plan to pay for the application of skin substitute graft. You say that this is supported in the 
records. The Plan denied your request. The Plan says this is not documented. 
 
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 15271 is application of skin substitute graft to trunk, 
arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. 
 
We find that CPT code 15271 is not supported in the medical record. Specifically, although the submitted 
records state that a graft was applied to all wounds, the specific type of graft and the surface area it was applied 
to are not documented. Without this information, this code cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the application of skin substitute graft have not been met. Therefore, we decided that the Plan does not have to pay for the application of skin substitute graft (15271) 
provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) when performed (77067) provided October 4, 2021. 
 You asked the Plan to pay for the diagnostic services. You say that due to your move you received your 
mammogram at a new location. You were unaware that it was done 21 days before it would have been a year. 
The Plan denied your request. The Plan says this service exceeds the maximum benefit allowed. 
 
The Plan follows Medicare rules. The rules say that the Plan covers one screening mammogram every 12 
months for women age 40 and over.  
 
The records show that this service was previously provided November 25, 2020. Based on review of the file, 
the mammogram was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided 
that the Plan does not have to pay for Screening mammography, bilateral (2-view study of each breast), 
including computer-aided detection (CAD) when performed (77067) provided October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided on September 
28, 2021, and a computed tomography (CT) scan of the head provided on October 15, 2021. 
 
You asked the Plan to waive the copayments for laboratory services and a CT scan. You say that you have had 
insurance with this company for over 40 years. You also say that you have never had a test like this before and 
should not have to pay for it. 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 in-network laboratory services in an outpatient hospital facility. The Plan contract also says that 
enrollees must pay a $100 copayment for in-network advanced imaging services, including CT scans. 
 
You have been asked to pay a $10 copayment for laboratory services. You have also been asked to pay a $100 
copayment for a CT scan. You have been asked to pay a total of $110 ($10 copayment + $100 copayment = 
$110). Laboratory services and a CT scan 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 copayments for laboratory services 
provided on September 28, 2021, and a computed tomography (CT) scan of the head provided on October 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza virus vaccination (90662) provided on October 
6, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for an influenza virus vaccination. You say that the service at issue was a necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care 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 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 influenza virus 
vaccination (90662) provided on October 6, 2021, by an out-of-network provider.