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

 
We decided that the Plan does not have to pay for an office visit (99204), scanning of a computerized 
ophthalmic diagnostic imaging (92133) and a gonioscopy (92020) provided on August 22, 2023. 
 
You asked the Plan to pay for an office visit, scanning of a computerized ophthalmic diagnostic imaging and a 
gonioscopy. You say that you have not had good experiences with the previous eye doctor. You also say you 
did not want to go back to him, so you paid $150 at the new place and are now being billed for additional 
services. The Plan denied your request. The Plan says while you are a member of the Plan, you must use 
network providers to get your medical care and services. 
 
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 the eyeglasses are received from an in-network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of an office visit, scanning of a computerized ophthalmic diagnostic imaging and a gonioscopy have 
not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204), scanning of 
a computerized ophthalmic diagnostic imaging (92133) and a gonioscopy (92020) provided on August 22, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each insulin infusion catheter provided on 
January 26, 2023, to June 09, 2023. 
 
You asked the Plan to waive the coinsurance for each insulin infusion catheter. You say that you should not 
have a cost for these supplies. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment, including diabetic supplies. 
 
You have been asked to pay 20% coinsurance for each insulin infusion catheter. This item/service falls within 
the durable medical equipment, including diabetic 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. The total amount you owe for each infusion 
catheter is $16.54 ($82.68 allowed amount x 20% = $16.54). Therefore, we decided that the Plan does not have 
to waive the coinsurance for each insulin infusion catheter provided on January 26, 2023, to June 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70486 billed for date of service September 
18, 2023.  
 
You asked the Plan to pay for procedure code 70486. You say that the claim is billed correctly and should be 
paid. 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 70486 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 70486 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 70486 billed for date of service September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0955 billed for date of service December 
12, 2022.  
 You asked the Plan to pay for procedure code E0955. You say that you have submitted medical records so that 
this claim can get processed correctly. 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 E0955 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 E0955 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E0955 billed for date of service December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service July 11, 
2023.  
 
You asked the Plan to pay for procedure code 87481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 87481 is 5. The MAI value for this code is 3. You billed 7 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 87481 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87481 billed for date of service July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination (92014) and an eye refraction 
(92015) provided on September 14, 2023.  
You asked the Plan to pay for a routine eye examination and an eye refraction. You say that you spoked with 
the provider, who confirmed that the examination was diagnostic in purpose. The Plan denied your request. The 
Plan says this benefit has been exhausted. 
 
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 examination (eye refraction) per year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye examination 
(eye refraction) per year. The record shows this benefit was exhausted on March 16, 2023. Based on this 
information, we decided that the Plan's rules for coverage of a routine eye examination and an eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination 
(92014) and an eye refraction (92015) provided on September 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum has already been exhausted. 
 
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, certain limitations apply. The record 
shows your $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on September 28, 
2023, to November 02, 2023. 
 
You asked the Plan to waive the coinsurance for injections. You say that this coinsurance is way too high and 
you cannot afford it. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $350.27 ($350.27 + $347.30 = $697.57). Therefore, we decided that the Plan 
does not have to waive the coinsurance for injections provided on September 28, 2023, to November 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0667, 
E0651). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the cause 
of the lymphedema was not clearly described or a plan for treating the root cause. Also, the measurements with 
and without a trial of a compression device were not clearly detailed in units. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve an intermittent limb compression device (E0667, E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 17, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the wig, any type (A9282) purchased August 12, 
2023. 
 
You asked the Plan to reimburse you for the wig. You say that you had this covered before with other 
insurances and you feel it should be covered by the Plan. The Plan denied your request. The Plan says wigs are 
not covered for the enrollee's diagnosis of Alopecia. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules.  
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig, 
any type (A9282) purchased August 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on August 18, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says the provider was out-of-network. 
 
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 received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on August 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necesary The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on October 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on August 22, 2023. 
 You asked the Plan to pay for the psychotherapy visit. You say that you are asking for the review of the 
submitted documents. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the psychotherapy visit provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 13, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 13, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan (procedure code 93925) rendered on September 29, 2023. 
 
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 that Current Procedural Terminology (CPT) code 93925 (1 unit) remains 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 93925 is "Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records document a well-
described bilateral lower extremity ultrasound of the lower extremity arteries. The exam should be reimbursed 
as it is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for a 
duplex scan (procedure code 93925) rendered on September 29, 2023.  
 
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 pay for the home visit for evaluation provided on June 26, 2023. 
 
You asked the Plan to pay for the home visit for evaluation. You say that you are requesting reconsideration for 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the home visit for evaluation provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 16, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on September 6, 2023. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were told this visit would be covered. 
The Plan denied your request. The Plan says your annual wellness visit benefit has already been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Specifically, the record shows you had an annual wellness visit on January 12, 2023. Therefore, we decided 
that the Plan does not have to pay for the annual wellness visit provided on September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 13, 2023, billed with 
codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81351-
90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90 GY x3. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 13, 2023, billed with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 
81317-90, 81321-90, 81351-90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90 GY x3.