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

 
We decided that the Plan does not have to pay for the eye exam (92002) and refraction (92015) provided on 
October 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and refraction. You say that you were advised that the refraction 
exam would be covered. You also say that although you were misinformed unintentionally, you feel 
reimbursement of $75.00 is warranted. The Plan denied your request. The Plan says these services were 
rendered by a non-contracted provider, and authorization was not obtained. The Plan also says the provided 
services were not urgent or emergent in nature. 
 
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 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 the eye exam (92002) and refraction (92015) 
provided on October 5, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13122 billed for date of service November 7, 
2022. 
 You asked the Plan to pay for procedure code 13122. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 13122 is bundled into payment for code 27048. 
 
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 13122 
is a column II code to column I code 27048. 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 13122 billed for date of service November 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
December 16, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
the services provided in this case. 
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have exhausted the allowable benefit for the 
acupuncture services provided in this case. Medicare rules say that no more than 20 acupuncture sessions are 
covered per year. The record shows that the Plan has previously paid for 20 acupuncture visits; therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for the acupuncture treatments (97810, 97811) provided on December 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on February 4, 2023. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you do not remember ordering these 
COVID-19 kits. You also say that you do not feel like you should be charged for this. The Plan denied your 
request. The Plan says at-home COVID-19 tests are not included within the Medical Benefits Chart of your 
2023 Evidence of Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests are an OTC item. The Plan does not offer a supplemental benefit covering this service. However, these could be obtained with participating providers and covered by Original Medicare when using 
your Medicare card rather than your Plan card. Therefore, we decided that the Plan does not have to pay for the 
at-home COVID-19 tests purchased on February 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional mileage for non-emergency 
transportation. 
 
You asked the Plan to pre-approve the additional mileage for non-emergency transportation. You say that you 
need to go to this appointment with your oncology doctor. The Plan denied your request. The Plan says the 
service is not a covered benefit.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of a 50-mile limit per trip trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested mileage is over the 50-mile limit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional mileage for non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatments (97810, 97811) provided on 
December 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
the services provided in this case. 
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have exhausted the allowable benefit for the 
acupuncture services provided in this case. Medicare rules say that no more than 20 acupuncture sessions are 
covered per year. The record shows that the Plan has previously paid for 20 acupuncture visits; therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for acupuncture treatments (97810, 97811) provided on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCISionRT test (0295U) provided on September 28, 
2022. 
 
You asked the Plan to pay for the DCISionRT test (0295U). You say that the DCISionRT test (0295U) 
provided on September 28, 2022, was medically necessary. The Plan denied your request. The Plan says the 
DCISionRT test (0295U) provided on September 28, 2022, was 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 pay for the DCISionRT test (0295U). Our reviewer says that the DCISionRT test (0295U) provided on September 28, 2022, was not medically necessary. Our 
physician reviewer found molecular testing to determine the need for additional therapy after surgery for ductal 
carcinoma in situ (DCIS) is not a standard of care. Use is not supported by the National Comprehensive Cancer 
Network (NCCN) Guidelines. The risk of ipsilateral recurrence in those in the low-risk group who did not 
undergo radiation therapy was still higher than the expected rate of contralateral breast disease. Further 
validation of these tests such as DCISionRT is warranted. The service is not reasonable or 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 DCISionRT test (0295U) have not been met. Therefore, we decided that the 
Plan does not have to pay for the DCISionRT test (0295U) provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on November 3, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee had undergone a trans-urethral resection of a bladder tumor (TURBT) on 
October 27, 2022 and presented to his urologist on November 2, 2022 with concerns of passing urinary blood 
clots and urinary retention. At that time 621ml of urine was found post-void residual in the enrollees bladder 
and a urinary catheter was inserted. Soon thereafter, the enrollee was admitted to the hospital as observational 
status. Continuous bladder irrigation was done, and his direct oral anticoagulant medication was stopped. By 
the next day, his urine flow was consistently reassuring to the urological team, and he was discharged home 
without any catheter. The review has determined that the record did not show that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided on November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should qualify for these benefits. The 
Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for complete denture - mandibular (D5120) and extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140) x8 provided on June 3, 2022. 
 
You asked the Plan to pay more for dental services. You say that you do not agree with the coinsurance for 
services you received. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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. Enrollees must pay 20% 
coinsurance for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and 40% 
coinsurance for complete denture - mandibular (D5120). 
 
You have been asked to pay a total of  $434.69 for dental services received on June 3, 2022. Allowed amount 
for D5120 $794.34 x 40% coinsurance = $317.73 and allowed amount for D7140 $73.14 x 20% coinsurance = 
$14.62 x 8 extractions = $116.96 ($317.73 + $116.96 = $434.69 total). 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 pay more for 
complete denture - mandibular (D5120) and extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140) x8 provided on June 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had an 
episode of severe hypoglycemia and received intravenous glucose. You also say that you became alert but then 
declined transportation to a medical facility despite medical advice. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
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 December 11, 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 with no 
transport provided on December 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
December 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
the services provided in this case. 
 
 
 
  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have exhausted the allowable benefit for the 
acupuncture services provided in this case. Medicare rules say that no more than 20 acupuncture sessions are 
covered per year. The record shows that the Plan has previously paid for 20 acupuncture visits; therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for the acupuncture treatments (97810, 97811) provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the corneal hysteresis determination provided on December 
19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the corneal hysteresis determination. You say that you are appealing this denial. 
 The Plan denied your request. The Plan says there is no prior authorization, and the provider was out-of-
network. 
 
 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 did not pre-approve the 
corneal hysteresis determination. We found no exception that would require the Plan to pay for these the 
corneal hysteresis determination. Therefore, we decided that the Plan does not have to pay for the corneal 
hysteresis determination provided on December 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a male erection device (L7900). 
 
You asked the Plan to pre-approve a male erection device. You say that you disagree with the denial and would 
like the plan to pay a portion of the cost for this device. The Plan denied your request. The Plan says the 
requested device is not a covered item under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a male erection device have not been met. Specifically, the requested device is statutorily non-
covered. Therefore, we decided that the Plan does not have to pre-approve a male erection device (L7900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as you do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service December 
15, 2022. 
 You asked the Plan to pay for procedure code 11720. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 11720 is bundled into payment for code 11721. 
 
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 11720 
is a column II code to column I code 11721. 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 11720 billed for date of service December 15, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 69990. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 69990 is bundled into payment for code 22610. 
 
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 69990 is a column II code to column I code 22610 with a modifier indicator of 0. The column II code is therefore 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 69990 billed for date of service December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee needs mobility assistance to get 
their mail, take out the trash, and use the laundry room outside their apartment. The Plan denied your request. 
The Plan says that the requested power scooter is not covered for outside use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.