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

 
We decided that the Plan does not have to pay for procedure code 77003 rendered on April 3, 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 CPT 77003 is an add-on code without the appropriate primary procedure code. 
 
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 7703 is an add-on code and has not been billed with an appropriate primary procedure code. 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 77003 rendered on April 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 1, 
2023. 
 You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70553. 
 
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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service April 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service January 1, 
2023.  
 
You asked the Plan to pay for procedure code 99222. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99222 is bundled into payment for code 99285. 
 
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 99222 
is a column II code to column I code 99285 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 99222 billed for date of service January 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on February 16, 2023.  
You asked the Plan to pay for contact lenses. You say that you are appealing with supporting records. 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 up to $150 for non-Medicare covered eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $150 allowance for non-Medicare 
covered eyewear every year. The record shows this benefit was exhausted with this service. Based on this 
information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for contact lenses provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic biometry (92136) provided 
on April 20, 2023. 
 
You asked the Plan to waive the copayment for an ophthalmic biometry (92136). You say that this facility is an 
all-inclusive facility with physician offices, eye examination rooms and a surgery center. You also say that the 
$75 charge for a test done at another location is not correct. 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 a $75 
copayment for procedures at any in-network other location. 
 
You have been asked to pay a $75 copayment for an ophthalmic biometry (92136). This item/service falls within the procedures at any in-network other location 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 record shows that this facility is considered an out-
patient facility and not a physicians office. Therefore, we decided that the Plan does not have to waive the 
copayment for an ophthalmic biometry (92136) provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue additional reimbursement for this service. 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 this service.   
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
   
 
 
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for the service provided in this case. Specifically, the Plans contract states that you are reimbursed up 
to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility. The 
Plan previously issued reimbursement to you on May 13, 2022 in the amount of $150 for this gym 
membership; therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that 
the Plan does not have to issue additional reimbursement for the gym membership (S9970) purchased on 
January 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on March 7, 2023, to 
March 8, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you bought your medications to the 
hospital with you. 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 
received on March 7, 2023, to March 8, 2023.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 3, 2022, 
through August 29, 2022. 
 You asked the Plan to pay for the home health services. You say that the enrollee was not on hospice during the 
dates of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from August 3, 2022, through August 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency stretcher van transportation (T2005) 
provided on December 28, 2022. 
 
You asked the Plan to pay for the stretcher van transportation. You say that you are requesting reimbursement 
for the stretcher van transport. The Plan denied your request. The Plan says enrollees must contact the 
designated provider to schedule a non-emergency trip. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for stretcher van transport 
services.  
 
The services you have asked the Plan to pay for are stretcher van transport services. Therefore, we decided that 
the Plan does not have to pay for non-emergency stretcher van transportation (T2005) provided on December 
28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 23, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you were unaware of the need for pre-
authorization. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 physical therapy 
provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided on January 1, 2021. 
 
You asked the Plan to reimburse for a gym membership provided. You say that you never received a 
reimbursement for the wellness allowance for the member for the year 2021. The Plan denied your request. The 
Plan says they did not receive your request until April of 2023. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the Pan receives the reimbursement request by no later than March 31st of the following year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the Plan did not receive the 
reimbursement request until April of 2023. The Plan rules say that reimbursement requests must be received by 
the Plan no later than March 31st of the following year. Therefore, we decided that the Plan does not have to 
reimburse for a gym membership provided on January 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on January 18, 2023, to 
February 22, 2023. 
 
You asked the Plan to pay for outpatient mental health. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 outpatient mental health 
provided on January 18, 2023, to February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), mechanical traction therapy (97012), 
electrical stimulation (G0283), x-ray exam of the cervical spine (72040), and the extraspinal chiropractic 
manipulative treatment (98943) provided from March 8, 2023, through March 27, 2023. 
 
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 these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), mechanical traction therapy (97012), electrical 
stimulation (G0283), x-ray exam of the cervical spine (72040), and the extraspinal chiropractic manipulative 
treatment (98943) provided from March 8, 2023, through March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on March 1, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you purchased these out of your provider 
network. The Plan denied your request. The Plan says the services were not provided by preferred network 
providers. 
 
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 when they are purchased in-network.  
 
We looked at this the file and the Plan's rules. The Plan rules say that you must select a device from the covered 
list available through our participating hearing aid supplier. The record shows these were purchased by an out-
of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
(V5261) have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) 
provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on  
May 2, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of 
residual tooth roots (D7250) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x3) provided on April 4, 2023. 
 
You asked the Plan to pay for surgical removal of erupted tooth. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical 
removal of erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x3) provided on April 4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for physical therapy provided on June 17, 2022, to 
January 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for physical therapy. You say that you needed to continue your physical 
therapy in order to recover from a stroke. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advanced. 
 
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 reimburse for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for physical therapy provided on June 17, 
2022, to January 25, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on April 4, 2023. 
 
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 do not meet criteria for coverage of the 
services provided.  
 
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, in order for services to be covered, 
members must receive dental care from their assigned dentist. The dental services in this case were not 
provided by your assigned dentist. Therefore, we decided that the Plan does not have to pay for the dental 
cleaning (D1110) and the periodic oral evaluation (D0120) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic retainer crowns for teeth number 22 
and 27 (D6740 x 2) and porcelain/ceramic pontics for teeth number 23, 24, 25, and 26 (D6245 x 4). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental policy.  
 
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 items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
porcelain/ceramic retainer crowns for teeth number 22 and 27 (D6740 x 2) and porcelain/ceramic pontics for 
teeth number 23, 24, 25, and 26 (D6245 x 4).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from October 24, 2022, 
to December 19, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you disagree with the copayment 
assessed. 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 $0 
copayment for days 1 to 20 and a $100 copayment for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $1,800 for SNF care ($100 per day x 18 days = $1,800). This item/service falls 
within the SNF care 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 SNF care provided 
from October 24, 2022, to December 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that having the enrollee continuing treatment 
will help to minimize future falls and avoid injury. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the enrollees medical condition. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.