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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 1,2023. 
 
You asked the Plan to pay for the billed code. You say that the service was denied in error. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on August 4, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed code have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 1,2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 72148 provided on August 9, 2023. 
 
You asked the Plan to pay for procedure code 72148. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure code 72148 based on Medicare criteria. The Plan has not provided any evidence that 
procedure code 72148 was billed and paid for by the Plan on another claim. Therefore, we decided that the Plan 
has to pay for procedure code 72148 provided on August 9, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that in-network providers are always late. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
transportation services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code is not payable. 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 64494 is an add-on code. Because the primary procedure code 64493 
is not payable in this case, the add-on code is also not payable. 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 64494 
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 an unspecified restorative procedure (D2999) provided on 
March 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
unspecified restorative procedure is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified restorative procedure (D2999) provided on March 14, 2023.
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 enrollee needs this care before 
returning home. The Plan denied your request. The Plan says the enrollee's needs can be managed at the current 
facility until they are more stable for transfer to another level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the services are currently available at the acute care hospital where the enrollee is 
currently receiving 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and evaluation (92014) and 
scanning computerized ophthalmic diagnostic imaging (92134) provided on May 1, 2023, by an out-of-network 
(OON) provider. 
 
  You asked the Plan to pay for the medical eye examination and evaluation and diagnostic imaging. You say 
that you were unaware at the time of the visit that you were non-participating with this patient's insurance. You 
also say that you are requesting this claim to be honored for payment as if you were in-network. The Plan 
denied your request. The Plan says the patient went to an OON provider without a referral, and the services 
rendered did not meet an exception. 
 
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 obtained from a provider in the Plans vision vendor 
network. 
 
We looked at the file and the Plan's rules. The record shows that the patient received these services from an 
OON provider, and they were not referred to this OON provider for care. Based on this information, we 
decided that the Plan's rules for coverage of the medical eye examination and evaluation and diagnostic 
imaging have not been met. Therefore, we decided that the Plan does not have to pay for the medical eye 
examination and evaluation (92014) and scanning computerized ophthalmic diagnostic imaging (92134) 
provided on May 1, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing code 87801 provided on June 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. 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, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing code 87801 provided on June 29, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic tests and an office visit 
provided on April 28, 2023. 
 
You asked the Plan to waive the cost share for outpatient diagnostic tests and an office visit. You say that you 
disagree with the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $400 deductible and a $25 copayment which applies to outpatient 
diagnostic tests and physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests 
and physician/practitioner services benefit category. The total amount you are being asked to pay towards your 
deductible is $33.75. The total amount you are being asked to pay is $58.75 ($33.75 + $25 = $58.75). The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible and a $25 copayment which applies to outpatient diagnostic tests and physician/practitioner services. This cost sharing is 
a contractual obligation that had not been met at the time outpatient diagnostic tests and an office visit was 
received on April 28, 2023. Therefore, we decided that the Plan does not have to waive the cost share for 
outpatient diagnostic tests and an office visit provided on April 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on September 23, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on September 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lens (V2203), photochromatic tint (V2744), and 
frames (V2020) purchased on August 19, 2023. 
 
You asked the Plan to pay for the eyewear. You say that you and the salesperson called to see how much your 
insurance would pay for your glasses, and you were advised the insurance would pay $400. 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 these services once per year. Any remaining benefit dollars do not "roll over" to a 
future purchase. 
 
 We looked at the file and the Plan's rules. The record shows that you already received a frame and lens package 
on March 23, 2023, which was paid by the Plan. 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 
bifocal lens (V2203), photochromatic tint (V2744), and frames (V2020) purchased on August 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan.  
 
You asked the Plan to pre-approve a PET/CT scan. You say that the requested imaging is medically necessary.  
The Plan denied your request. The Plan says a CT scan should show the provider all the details needed to treat 
the enrollee.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a PET/CT scan. Our reviewer says that 
the requested imaging is not medically necessary. Our physician reviewer found previous mammogram and 
ultrasounds were unremarkable as well as PET scan showing no FDG activity. A 1 cm non-avid ground-glass 
opacity lesion in the right upper lobe lung was seen and recommended to monitor with repeat imaging. A PET 
can was ordered for follow-up. Given that the lung lesion is non-FDG avid, it appears this could be monitored 
with CT scan alone and PET scan would not add additional benefit.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET/CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthosis procedure code L1851 billed for date of service 
August 18, 2023. 
 
You asked the Plan to pay for the billed service. 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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The ordering physician is not consistent with the physician in 
the medical records provided. The records that were provided do not show that the orthosis was part of the 
enrollees treatment plan, or that the orthosis was needed for a specific and active medical condition. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for orthosis procedure code L1851 billed for date of service August 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational for intercostal neuralgia. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on November 14, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 on November 14, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2023. 
 
You asked the Plan to pay for the office visit. You say that you ended hospice care on August 17, 2023. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 an office visit provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear (codes V2020, V2750, V2755, V2781, and 
V2784) purchased on July 24, 2023, from a non-Plan approved vision vendor. 
 
You asked the Plan to pay for the eyewear. You say that you called the Plan in 2021 for a referral for a vision 
doctor and eyewear provider, and were referred to a provider at this facility. In 2023 you went to this same 
provider you were referred to, got new glasses, and submitted the bill for reimbursement. You also say that you 
assumed since your vision insurance had not changed and you went to the provider the Plan sent you to, that 
you would be reimbursed like last time. The Plan denied your request. The Plan says the treating provider was 
not contracted to provide vision services or vision eyewear for your benefit plan. The Plan also says that you 
spoke with them on May 7, 2021, and the Plan advocate advised you of another Plan-approved vision provider 
who was in the network at the time and gave all pertinent information. 
 
 
 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 the Plan's approved hearing aid vendor to use your 
vision benefits. 
 
We looked at the file and the Plan's rules. The record shows that you self-referred to a non-participating 
provider, which is excluded as per the Plan benefits. Only participating providers are eligible for coverage for 
your plan. Self-referred specialist visits are not covered by the Plan. 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 eyewear (codes V2020, V2750, V2755, V2781, and V2784) purchased on July 24, 2023, 
from a non-Plan approved vision vendor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Apple watch and sales tax, purchased on July 15, 2023. 
 
You asked the Plan to pay for the Apple watch and sales tax. You say that the items were medically necessary. 
The Plan denied your request. The Plan says the watch is not primarily medical in nature and sales tax is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  Medicare does not reimburse separately for sales tax.  
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the Apple watch and sales tax, purchased on July 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77014 billed for date of service July 19, 
2023. 
 You asked the Plan to pay for the billed service. You say that authorization was not required. The Plan denied 
your request. The Plan says the billed code is a packaged service. 
 
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 looked at the file and the rules. Code 77014 has a status indicator of N. We find that code 77014 is 
packaged a packaged service and not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 77014 billed for date of service July 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 10, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the claim be reprocessed and paid. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 services provided on February 10, 2023.