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

We decided that the Plan has to pay for out of area services provided on August 30, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says that this provider was not in network. We upheld the Plan's
denial. Upon further review, we reopened the case due to a process error.
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. There were no medical records submitted with the case file that
would allow us to determine this situation was not urgent our emergent while out of area and/or out of network.
Therefore, we decided that the Plan has to pay for out of area x-rays of the ankle provided on August 30, 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 the routine eye exam (S0621, 92015) provided on December 
13, 2021. 
 
You asked the Plan to pay for routine vision services. You say that you only had one eye exam which was 
provided on December 15, 2021, and you do not know why you are being told you owe $165. You feel there must have been an error. The Plan denied your request. The Plan says your benefit covers one routine eye exam 
per calendar year. The Plan has a claim for a routine exam on December 15, 2021, which has been paid. 
Therefore, the second exam provided on December 13, 2021, exceeds the frequency limitation of your benefit 
for one routine eye exam per year. 
 
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 routine eye exam with refraction and dilation per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan has paid for one routine eye exam for 
you in 2021, and the exam at issue exceeds the limitations of your benefit. Based on this information, we 
decided that the Plan's rules for coverage of routine vision services have not been met. Therefore, we decided 
that the Plan does not have to pay for the routine eye exam (S0621, 92015) provided on December 13, 2021.  
 
Your complaint about a potential billing issue by a contracted provided for supplemental benefits 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid you purchased on December 15, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that due to COVID-19, you could not get anyone to take 
you to the ear doctor, so you had to go to this provider instead. The Plan denied your request. The Plan says 
hearing aids purchased out-of-network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use their designated hearing aid vendor.  Hearing aids purchased from any other 
provider are not covered, regardless of the reason. 
 
Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aid you purchased on December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 10, 2021. 
 
You asked the Plan to pay for the medical services. You say that this service should be covered because it was 
an initial consultation visit with an oncologist. You said that you have PPO coverage, so this should be 
covered. The Plan denied your request. The Plan says services provided by a provider who has opted out of 
Medicare are not covered. 
 
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 the 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 September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 July 21, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 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 September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you were obligated to process these specimens. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 the lab 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 lab services provided on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with a diagnosis of metastatic squamous cell carcinoma of tongue and underwent complex 
surgery that includes bilateral neck dissection, right mandibulectomy, left segmental mandibulectomy, total 
glossectomy, retromolar trigone resection, floor of the mouth resection, total laryngectomy, partial 
pharyngectomy, total thyroidectomy, cricopharyngeal myringotomy, and tracheoesophageal puncture. The 
record indicates that the enrollee requires ongoing acute care services before transitioning to a lower level of 
care. The enrollee continues to receive acute care services, and these have not been denied.  
 The medical record does not indicate that the enrollee requires services that he is not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with acute kidney injury in the setting of influenza pneumonia. The record indicates that the 
enrollee is improving but still requires ongoing acute care services before transitioning to a lower level of care. 
The enrollee continues to receive acute care services, and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 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 March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a modifier was not billed on the claim to represent the services as separate or distinct. 
 
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 71046 
is a column II code to column I code 32557. 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 imaging services provided to the enrollee on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550, A4556, A4557, A4649, S1015, and 
S8301 billed for date of service June 14, 2021. 
 
You asked the Plan to pay for procedure codes A4550, A4556, A4557, A4649, S1015, and S8301. You say that 
these claims should be paid as in-network because an in-network surgeon was used. The Plan denied your 
request. The Plan says no separate payment is made for these codes 
 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 codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This 
means that CPT codes S1015 and S8301 are not valid for Medicare purposes. In addition, CPT codes A4550, 
A4556, A4557, and A4649 have a Status Indicator of B on the Physician Fee Schedule. This means that 
payment for these codes is always bundled into payment for other services and no separate payment is made for 
them. Based on this information, we decided that Medicare rules for coverage of procedure codes A4550, 
A4556, A4557, A4649, S1015, and S8301 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes A4550, A4556, A4557, A4649, S1015, and S8301 billed for date of service 
June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be processed. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 the lab 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 lab services provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or skilled therapy needs. The enrollee is not shown to have an acute decline in function or 
to be able to participate in daily skilled therapy. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility services provided July 02, 2021 to July 19, 
2021. 
 
You asked the Plan to pay for skilled nursing facility services. You say that you had to pay-out-pocket for the 
skilled nursing services. The Plan denied your request. The Plan says that the services were obtained without 
prior authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not include any evidence to support that you had exhausted your 
skilled nursing facility benefit. The file submitted by the Plan does not include any records to support the 
number of days that you were admitted to the skilled nursing facility.  It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plans denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for skilled nursing facility services provided 
July 02, 2021 to July 19, 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 pre-approve a filling for a crown with posts for teeth #18 and 19 
(D2950). 
 
You asked the Plan to pre-approve a filling for a crown with posts for teeth #18 and 19. You say that the 
service is necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
filling for a crown with posts for teeth #18 and 19 (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service August 13, 
2021. 
 
You asked the Plan to pay for procedure code 99292. You say that the physician documented more than 30 
minutes of critical care time, so the coding is supported in the medical record. The Plan denied your request. 
The Plan says the medical records do not support payment of this code. 
 
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, you billed with critical care code 99292.  The medical record documents a total of 39 critical care minutes. According to Medicare billing rules, code 99291 should be used for critical care services lasting 
between 30 and 74 minutes.  Any time beyond 74 minutes should be billed using a unit of 99292 in addition to 
a unit of 99291.  However, you only billed a unit of 99292, which is not appropriate for a 39-minute critical 
care service.  
 
We find that CPT code 99292 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99292 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99292 billed for date of service August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose 
monitor (CGM) sensor.