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

 
We decided that the Plan does not have to waive the deductible for the anti-reflective coating (V2750), 
progressive lens (V2781), and high-index lens (V2782) provided on July 7, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to waive the deductible for the anti-reflective coating, progressive lens, and high-index 
lens. You say that according to your 2022 EOC, one pair of eyeglasses will be covered at no cost to you after 
cataract surgery. You also say that the surgery was done by an in-network doctor. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 deductible which applies to Vision care.  
 
The item or service you asked the Plan to waive the deductible for falls within the out-of-network Vision care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,500 deductible which applies to out-of-network Vision care. This cost sharing is a contractual obligation 
that had not been met at the time the anti-reflective coating, progressive lens, and high-index lens was received 
on July 7, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the anti-
reflective coating (V2750), progressive lens (V2781), and high-index lens (V2782) provided on July 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the contact lenses (V2500) purchased on November 21, 2022 
 
You asked the Plan to pay for the contact lenses. You say that this claim is for reimbursement of your out-of-
pocket expenses related to the purchase of contact lenses. You also say that the advocate you spoke with 
suggested you file this appeal. The Plan denied your request. The Plan says that this service is a covered 
benefit, but you have exceeded the frequency limitation in the benefit plan. 
 
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 records do not support that this request has exceeded the frequency 
limitation in the benefit plan. This means that the Plan has not provided a valid reason for denying payment of 
the contact lenses. Specifically, the documentation does not show what type of contact lenses have been paid 
for by the Plan, or the quantity that was covered. The provided records also do not show that the $100 
allowance has been exhausted. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for the contact lenses (V2500) purchased on November 21, 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 preapprove the additional transportation trips. 
 
You asked the Plan to preapprove the additional transportation trips. You say that you are a disabled veteran, 
and you need the additional transportation to attend your dialysis treatments. You say you were told you would 
have unlimited rides. The Plan denied your request. The Plan says the benefit limits have been exceeded. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way non-emergency transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the trips requested are beyond the 48 trips covered by the Plan. Therefore, we decided that the Plan does 
not have to preapprove the additional transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 22, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close medical 
monitoring for their complex medical condition. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided October 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on October 3, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this device was used outside the home and is non-
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 4, 2022. 
 
You asked the Plan to pay for the medical services. You say that you have provided operative reports, but do 
not participate with Medicare. The Plan denied your request. The Plan says you have opted out of Medicare, so 
you cannot be paid for these services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical 
services provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31615 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 31615. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 31615 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 31615 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 31615 billed for date of service February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service September 
13, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that your physician provided medically 
necessary services to the enrollee in good faith, and the rendered services meet professionally recognized 
standards of healthcare. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service September 13, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 1, 2022, 
to December 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for each admission to home health, the HHA notifies 
Medicare systems via submission of an NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 1, 2022, to 
December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided October 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 26, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 86077 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 86077 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 86077 billed for date of service November 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 21, 
2022. 
 You asked the Plan to pay for procedure code 0003A. You provided a citation for a rule in support of payment 
of this claim. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 7, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary and 
provided in good faith. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service August 7, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit and incision and removal of foreign 
body, subcutaneous tissues provided on September 29, 2021. 
 
You asked the Plan to pay for the emergency department visit and incision and removal of foreign body, 
subcutaneous tissues. The Plan denied your request. The Plan says that the provider waited over 12 months 
from the notice to file a correct claim. 
 
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 not provided proof that the claim was filed untimely. 
Therefore, we decided that the Plan has to pay for an emergency department visit and incision and removal of 
foreign body, subcutaneous tissues provided on September 29, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95913 billed for November 17, 2022. 
 
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 procedure code 95913 is not supported. 
 
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 95913 is nerve conduction studies; 13 or more studies. 
 
We find that CPT code 95913 is not supported in the medical record. Specifically, there is no documentation of 
13 or more nerve conduction studies. There is a more appropriate code for the services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 95913 billed for November 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 26341 provided on June 14, 2022. 
 
You asked the Plan to pay for procedure code 26341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to deny payment for 
procedure code 26341 based on Medicare criteria. Therefore, we decided that the Plan has to pay for procedure 
code 26341 provided on June 14, 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.