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

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
chest.  
 
You asked the Plan to pre-approve a CTA. You say that you are requesting a CTA of the chest for post-
operative evaluation of a Watchman device to assess proper healing. The Plan denied your request. The Plan 
says a post-operative CTA is not indicated for a Watchman device.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CTA. Our reviewer says that the 
service is not medically reasonable and necessary. Our physician reviewer found the clinical guidelines for the 
use of CTA following left atrial appendage occlusion (LAAO) device placement have not been met. LAAO 
device placement does not require post-procedure CTA imaging to assess healing. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomographic angiography (CTA) of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service May 22, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services must be submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. The Plan has contacted the provider to obtain the primary EOB. 
As the secondary insurer, the Plan cannot be held responsible for procedure code 99291 until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 for date of service May 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF stay from January 1, 2023, through 
January 31, 2023. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you cannot afford to pay the copayment 
for this SNF stay. 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 per 
day, days 1-20; $184 per day, days 21-100 for each Medicare-covered SNF stay.  
 
  You have been asked to pay a total of  $2,760 for the SNF stay. You were billed for January 17, 2023, through 
January 31, 2023, which is 15 days ($184 copayment x 15 days = $2,760). The SNF stay falls within the skilled 
nursing facility (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 stay 
from January 1, 2023, through January 31, 2023.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services provided as part of a clinical trial (S9988, 
S9990, S9991). 
 
You asked the Plan to pre-approve the services provided as part of a clinical trial. You say that this service is 
medically necessary. The Plan denied your request. The Plan says services provided as part of a clinical study 
are covered by Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for services provided as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve services provided as part of a clinical trial (S9988, S9990, S9991).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service February 17, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monkeypox vaccination provided on October 19, 2022. 
 
You asked the Plan to pay for the monkeypox vaccination. You say that you are in network and the service was 
billed properly. The Plan denied your request. The Plan says that the monkeypox vaccination is not a covered 
service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the monkeypox 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the monkeypox 
vaccination. Therefore, we decided that the Plan does not have to pay for a monkeypox vaccination provided 
on October 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided on September 27, 2022. 
 
You asked the Plan to pay for speech therapy. You say that you are appealing the claim payment denial. 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 speech therapy provided 
on September 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on August 15, 
2022, to December 28, 2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that you are requesting a 
reconsideration of the denied charges. 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 an outpatient mental 
health visit provided on August 15, 2022, to December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single lens, the frames, and the refraction provided on 
February 23, 2023. 
 
You asked the Plan to pay for the single lens, the frames, and the refraction. You say that you paid $48.93 for 
two pairs of glasses with an eye examination. You say that you have a $200 allowance towards glasses and 
fitting. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 up to a $100 benefit towards the purchase and fitting of 
eyeglasses and pair of lenses (one per calendar year). 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $100 allowance of the retail value 
of the eyewear, which exhausted the benefit. Based on this information, we decided that the Plan's rules for 
coverage of the single lens, the frames, and the refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the single lens, the frames, and the refraction provided on February 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from January 13, 
2023, to January 21, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you do not believe the enrollee 
should have two separate copayments because they never left the hospital. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 per day for days 1 to 6 for each Medicare-covered hospital admission.  
 
 
  The enrollee has been asked to pay a $1,950 for an IRF stay ($325 per day x 6 days = $1,950). This 
item/service falls within Inpatient Hospital Care benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an IRF stay provided from January 13, 2023, to January 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), tint photochromatic lenses (V2744), anti-
reflective coating (V2750), progressive lenses (V2781) and lenses (V2782) provided on February 8, 2023. 
 
You asked the Plan to pay for frames (V2020), tint photochromatic lenses (V2744), anti-reflective coating 
(V2750), progressive lenses (V2781) and lenses (V2782). You say that you checked to be sure this provider 
was in-network. You also say you do not understand why this was denied. The Plan denied your request. The 
Plan says they did not deny the services. The Plan also says that the claims processed correctly per your policy. 
 
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 $245 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $245 every year for non-
Medicare covered prescription eyewear. The records show the benefit was exhausted with this claim, and you 
are responsible for anything above the $245 allotment.  
 
Procedure Code: Amount Billed: Plan Payment: Enrollee Responsibility: 
V2020 $139.95 $139.95 0.00 
V2744 $55.00 $55.00 0.00 
V2744 $55.00 $50.05 $4.95 
V2750 $70.00 0.00 $70.00 
V2781 $174.95 0.00 $174.95 
V2782 $75.00 0.00 $75.00 
Total: $569.90 $245.00 $324.90 
 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020), tint photochromatic 
lenses (V2744), anti-reflective coating (V2750), progressive lenses (V2781) and lenses (V2782) have not been 
met. Therefore, we decided that the Plan does not have to pay for frames (V2020), tint photochromatic lenses 
(V2744), anti-reflective coating (V2750), progressive lenses (V2781) and lenses (V2782) provided on February 
8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that it is your professional opinion that this is the right 
therapeutic option for the enrollee. 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 pre-approve Dupixent.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visit for assessment and management provided on 
November 09, 2022. 
 
You asked the Plan to pay for a visit for assessment and management. You say that the records attached 
support 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 a visit for assessment 
and management provided on November 09, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 8, 2023, to 
January 30, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 9, 2022. The NOA was not received by the Plan until February 
16, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided January 8, 2023, to January 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 4, 2023, 
to February 9, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you wanted to discharge the enrollee 
on January 20, 2023 to avoid the daily copayment but the facility would not allow it since the enrollee had 
Covid-19. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 The enrollee has been asked to pay a $3,136 copayment for a SNF stay ($196 per day x 16 days = $3,136). This 
item/service falls within the SNF care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SNF stay provided from January 4, 2023, to February 9, 2023.  
 
Your complaint about the facility not discharging the enrollee due to testing positive for Covid-19 is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden genetic testing (81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that you are appealing the denial of Factor V 
Leiden CPT code 81241 for the enrollee. The Plan denied your request. The Plan says there is insufficient 
evidence in the published peer- reviewed scientific literature to support coverage for genetic testing for people 
other than pregnant women. 
 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. Medicare does not cover this genetic testing unless you are pregnant. 
The records show that the enrollee is not pregnant. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve Factor V Leiden genetic testing (81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support 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 laboratory services 
provided on October 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on February 27, 2023. 
 
You asked the Plan to pay for wound care. You say that you are appealing the claim payment denial. 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 wound care provided on 
February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97597 & 97598 provided on September 22, 
2022. 
 
You asked the Plan to pay for procedure codes. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are 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 CPT code. 
 
We find that CPT code 97597 & 97598 is not supported in the medical record. Specifically, the services were 
included in codes 11042 & 11045. There is no record of a debridement being performed so the size of the 
wound and number of units cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of procedure codes have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97597 & 97598 provided on September 22, 2022.