Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient colonoscopy services 
provided December 1, 2021, to December 4, 2021. 
 
You asked the Plan to waive the copayment for the outpatient colonoscopy services. You say that 
hospitalization was necessary. The Plan denied your request. The Plan says the copayment has been applied 
correctly. 
 
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 $325 
copayment a diagnostic colonoscopy performed as a hospital service. 
 
You have been asked to pay a $325 copayment for the outpatient colonoscopy services. The outpatient colonoscopy services 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 copayment for the outpatient colonoscopy services provided 
December 1, 2021, to December 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 16, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you had a severe reaction to insulin. You 
say that the Plan Guide for 2022 indicates there is a $0 copay for ambulance services. You also say that you do 
not understand why calling an ambulance in this emergency would not be a covered expense. The Plan denied 
your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on January 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care provided on January 16, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary and 
rendered in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care provided on January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Methylenetetrahydrofolate reductase (MTHFR) genetic 
testing provided on November 30, 2021. 
 
You asked the Plan to pay for the MTHFR genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the MTHFR gene is only covered for 
enrollees who are pregnant. 
 
 We looked at the file and Medicare rules. Review of the file does not support that the enrollee was pregnant. 
Based on this information, we decided that Medicare rules for coverage of the MTHFR genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the Methylenetetrahydrofolate reductase 
(MTHFR) genetic testing provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM) and 
supplies 
 
You asked the Plan to pre-approve the CGM and supplies. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for a CGM have not been satisfied. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic 
continuous glucose monitor (CGM) and supplies
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on February 10, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that it wasn't possible to get the authorization before 
the services were rendered. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telehealth visit provided on February 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has underlying conditions 
that will compromise her health. The Plan denied your request. The Plan says the enrollee is not under the care 
of a physician. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of diabetes mellitus with neuropathy and peripheral vascular 
disease with previous leg amputation who has been receiving skilled nursing care at home. The documentation 
indicates that the enrollee is medically stable and is able to transfer and use a wheelchair without assistance. 
The enrollee does not require additional skilled nursing or rehab services to effectively provide treatment in 
order to improve their condition, perform a maintenance program to maintain their condition or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 provided on January 7, 2022. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation shows 
that there has been another evaluation and management code previously billed for this Tax identification 
number/specialty for this enrollee in the claim history. This means a new patient office visit is not supported by 
the documentation. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 
provided on January 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on March 1, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for use of a hot/cold pack provided on March 29, 2022. 
 
You asked the Plan to hold you harmless for hot/cold pack. You say that you did not realize that you would be 
charged to use a heating pad. The Plan denied your request. The Plan says that the denial of payment for this 
service is correct, because this service is always bundled for payment and is not separately payable. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
This service was performed by a contract provider. The file does not show that the Plan provided notice that 
hot/cold pack would not be covered. Under Medicare rules, this means hot/cold pack is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold you harmless for use of a hot/cold pack provided on 
March 29, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen collection for severe acute respiratory 
syndrome coronavirus 2 (G2023) and PCR diagnostic panel (U0001) provided on November 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services rendered were not related to the 
enrollee's hospice election. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the specimen collection for severe acute respiratory syndrome 
coronavirus 2 (G2023) and PCR diagnostic panel (U0001) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
February 14, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you have gone to this dentist 
for the past four or five years, and the Plan has always paid this part of the bill. The Plan denied your request. 
The Plan says your benefit plan does not cover this out-of-network vision care service.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that this refraction was performed during a medical 
eye exam. Based on this information, we decided that the Plan's rules for coverage of the determination of 
refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the 
determination of refractive state (92015) provided on February 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 17, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that per Medicare eligibility the 
enrollee's Medicare Advantage Plan is active as of August 17, 2021. The Plan denied your request. The Plan 
says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan 
also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field examination (92083), 
scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, 
unilateral or bilateral; optic nerve (92133) and office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
high level of medical decision making (99215) provided August 10, 2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you did not receive any 
services on this day. The Plan denied your request. The Plan says the copayment has been applied correctly. 
 
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 $40 
copayment for each Medicare-covered eye exam. 
 You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the 
Vision services 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. Medical records were provided and show that these services were provided on August 10, 2021. 
Therefore, we decided that the Plan does not have to waive the copayment for the visual field examination 
(92083), scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and 
report, unilateral or bilateral; optic nerve (92133) and office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
high level of medical decision making (99215) provided August 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on May 14, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix. 
 
You asked the Plan to pre-approve Epifix. You say that you would like the plan to reconsider their denial The 
Plan denied your request. The Plan says the requested services 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 Epifix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are not diabetic. Treatment of non-healing diabetic lower-extremity ulcers using the 
following human amniotic membrane products (Affinity, AmnioBand Membrane, Biovance, EpiCord, EpiFix, 
Grafix) may be considered medically necessary, while all other human amniotic membrane products and 
indications not listedabove are considered investigational, including but not limited to treatment of lower- 
extremity ulcers due to venous insufficiency, osteoarthritis and plantar fasciitis. As you do not have a non-
healing diabetic lower extremity ulcer, this is considered investigational. Therefore, you do not meet criteria for 
the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to return the copayment for a specialist visit on March 1, 2022. 
 
You asked the Plan to return the copayment for a specialist visit. You say that the provider made you wait for a 
long period of time for a procedure. You left without having the procedure done, and you feel your $25 
copayment should be refunded. The Plan denied your request. The Plan says there is a $25 copay for each 
Medicare covered specialist visit. You were still seen in the office before the procedure. 
 
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 $25 
copayment for Medicare covered specialist visits.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the Medicare-
covered specialist visits 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 return the copayment for a specialist 
visit on March 1, 2022.