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

 
We decided that the Plan does not have to pay for the radiologic examination of the abdomen (74019), 
provided on September 20, 2021. 
 
You asked the Plan to pay for the radiologic examination of the abdomen. You say that the service should be 
covered. The Plan denied your request. The Plan says they did not receive the EOB from the member's primary 
insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the radiologic examination of the abdomen until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the radiologic examination of the abdomen 
(74019), provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the doctor was in and out 
of the office in ten minutes. You also say that the doctor did not do anything but order a magnetic resonance 
imaging (MRI) exam. 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 $45 
copayment for a specialist office visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office 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 waive the copayment for a specialist office visit provided on December 22, 2021.  
Your complaint about the amount of the time the provider spent with you and her only ordering an MRI 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 eye exam (92012), provided on December 3, 2021. 
 
You asked the Plan to pay for the eye exam. You say that the services were rendered in good faith. The Plan 
denied your request. The Plan says services must be obtained through participating providers. 
 
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 you use a participating provider. 
 
We looked at the file and the Plan's rules. The service was obtained through an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92012), provided on December 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the determination of refractive state (92015), provided 
on October 1, 2021. 
 You asked the Plan to pre-approve the determination of refractive state. You say that the service should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pre-approve the determination of refractive state (92015), provided 
on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have o pay for a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan o pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says this item is not covered for the prevention of venous thrombosis 
during or after 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 o pay 
for a pneumatic compression device (E0675 and E0673).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical arthroscopy of the knee (29876, 29881) provided on 
August 30, 2021. 
 
You asked the Plan to pay for surgical arthroscopy of the knee. You say that these procedures were medically 
necessary and are eligible for separate reimbursement when billed together. The Plan denied your request. The 
Plan says the requested codes are reported with the same base procedure and have a multi procedure code of 3. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 29876 and 29881 are not supported in the medical record. Specifically, the record 
indicates that the Plan paid the full value of the highest valued endoscopy, plus the difference between the next 
highest and the base endoscopy. Based on this information, we decided that Medicare rules for coverage of 
surgical arthroscopy of the knee have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical arthroscopy of the knee (29876, 29881) provided on August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 13, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from September 1, 2021, to September 3, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you have had several hospital stays in 
the last few years. You say that you have never had to pay for any medication that you received until now. You also say that this bill is a hardship for you as you are on a limited income. The Plan denied your request. The 
Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from September 1, 2021, to September 3, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), progressive lens (V2781), and sales tax 
(S9999), provided on November 13, 2021. 
 
You asked the Plan to pay for the eyewear. You say that the service should be covered. The Plan denied your 
request. The Plan says you have exceeded the Plan's maximum allowance for this benefit. 
 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 up to a $200 benefit allowance per a year for prescription eyewear. 
 
We looked at the file and the Plan's rules. You have exceeded the Plan's maximum allowance for this benefit. 
Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames (V2020), progressive lens (V2781), and 
sales tax (S9999), provided on November 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot supports (L3040), heel wedge (L3350), durable 
medical equipment (DME) (E1399), and sales tax (S9999). 
 
You asked the Plan to pay for the foot supports, heel wedge, other DME and sales tax. You say that you need 
these items. The Plan denied your request. The Plan says you obtained these items through a provider who is 
not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the foot supports (L3040), heel wedge 
(L3350), durable medical equipment (DME) (E1399), and sales tax (S9999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for glucose monitoring provided on November 
10, 2021. 
 
You asked the Plan to waive the copayment for glucose monitoring. You say that according to your insurance 
card your copayment should only be $40. 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 $30 
copayment for non-radiological diagnostic services.  
 
The glucose monitoring you received is considered a separately payable service from the specialist office visit 
you had on November 10, 2021. You have been asked to pay a $30 copayment for glucose monitoring. Glucose monitoring 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 glucose monitoring provided on November 10, 
2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown for tooth #9. We decided that the Plan does not have to 
pre-approve a crown for tooth #22.  
 
You asked the Plan to pre-approve a crown. You say that these services are medically necessary. The Plan says 
that the criteria for D2740 has not been met. 
 
We decided that the Plan has to pre-approve D2740 for tooth #9.  
 Our doctor found that the documentation provided meets the criteria for coverage for a crown restoration 
(D2740) for tooth #9 but does not meet the criteria for coverage for a crown restoration for tooth #22 due to 
lack of diagnostic radiographs. Therefore, we decided that the Plan has to pre-approve D2740 for tooth #9.  
 
We also decided that the Plan does not have to pre-approve D2740 for tooth #22. 
 
 Diagnostic radiographs were not provided for tooth #22. Therefore, we decided that the Plan does not have to 
pre-approve. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a follow up 
appointment after surgery to see if it healed. You also say that this visit should have been included with the 
surgery charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. The Plan also says that there was a 90-day global surgery period, which ended on July 11, 2021. 
 
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 $35 
copayment for a specialist office visit.  
 
The record shows the global surgery period for your procedure had ended on July 11, 2021. You have been 
asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office 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 waive the copayment for a specialist office visit provided on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650) provided on July 27, 2021. 
 You asked the Plan to pay for the back brace. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the actual face-to-face office visit was conducted on 
May 19 and June 22, 2021, and the prescription and/or order form was signed August 26, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that as a condition for payment, 42 CFR 410.38 and 
Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a 
beneficiary within the six (6) months prior to prescribing items that appear on the Required List. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the back brace have not been met. Specifically, the documentation submitted does not include any 
evidence that there was a face-to-face visit within 6 months prior to the prescription of the back brace at issue 
Therefore, we decided that the Plan does not have to pay for the back brace (L0650) provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
30, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 30, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
17, 2021. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 76705 is bundled into payment for 93976.  
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 procedure code 76705 billed for date of service November 17, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0999) provided on 
October 26, 2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you were picked up from your 
home by the ambulance, taken to the fire department, picked up by an Emergency Medical Technician (EMT), 
and transported to the hospital. You also say that you had no idea what was going on this entire time. The Plan 
denied your request. The Plan says your coverage does not provide for this ambulance service. 
 
  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services (A0999) provided on October 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens sphere single plano 4.00 (V2100), and anti-reflective 
coating (V2750) provided on November 24, 2021. 
 
You asked the Plan to pay for the vision care. You say that you had cataract surgery before you enrolled in 
hospice. You say that the glasses you received were a result from the cataract surgery. You also say that this 
bill should be covered. 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 lens sphere single plano 4.00 (V2100), and anti-reflective 
coating (V2750) provided on November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure code 97530) provided to the 
enrollee on May 14, 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 the provider did not bill as required 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 97530 
is a column II code to column I code 92526. 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 therapy services (procedure code 97530) provided to the enrollee 
on May 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 
9, 2021, to August 31, 2021. 
 
You asked the Plan to pay for home health services. You say that there wasn't enough time to submit this 
information. The Plan denied your request. The Plan says the initial Request for Anticipated Payment (RAP) 
claim was not submitted within five calendar days from the start of care. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from July 9, 
2021, to August 31, 2021.