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

 
We decided that the Plan does not have to pay for polarization (V2762), frames (V2020), single vision lenses 
(V2100), polycarbonate lenses (V2784), and a vision supply or accessories (V2797) provided on July 11, 2023. 
 
You asked the Plan to pay for polarization (V2762), frames (V2020), single vision lenses (V2100), 
polycarbonate lenses (V2784), and a vision supply or accessories (V2797). You say that you had seen an in-
network optician and ordered glasses from them. You also say there was an issue with the glasses, and you 
returned them after two days. You also say that the Plan should deny those charges and accept this rendering 
provider's charges. The Plan denied your request. The Plan says the 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 when . 
 
We looked at the file and the Plan's rules. The Plan rules say they have a $100 allowance for routine eye wear 
every year (including eyeglass frames, lenses, and contract lenses). The record shows that the benefit was 
exhausted with this date of service. Based on this information, we decided that the Plan's rules for coverage of 
polarization (V2762), frames (V2020), single vision lenses (V2100), polycarbonate lenses (V2784), and a 
vision supply or accessories (V2797) have not been met. Therefore, we decided that the Plan does not have to 
pay for polarization (V2762), frames (V2020), single vision lenses (V2100), polycarbonate lenses (V2784), and 
a vision supply or accessories (V2797) provided on July 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sleep study provided on May 28, 2023. 
 
You asked the Plan to pay for the sleep study. You say that you are requesting reconsideration of the denied 
claim. 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 the sleep study provided 
on May 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Single Photon Emission Computed Tomography 
(SPECT) (78452). 
 
You asked the Plan to pre-approve a SPECT test. 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 a SPECT test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the electrocardiogram shows an uninterpretable pattern. There is 
no evidence provided that would support the need for radionuclide stress testing. 
 
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 SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Single Photon Emission Computed Tomography (SPECT) (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the medical necessity guidelines for this procedure because 
the enrollee is able to take oral anticoagulant medications. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that LAAC is covered when specific criteria are met, such as if 
the enrollee is unable to take oral anticoagulants. 
 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 LAAC. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the expense of anticoagulation is cited, as his insurance carrier has declined coverage. There is 
no apparent contraindication to anticoagulation. As such, guidelines would not support implantation of a 
LAAC in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve left atrial appendage closure device (LAAC) (33340).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory panel provided on February 25, 2022, billed with code 
0202U. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the laboratory panel 
billed have been met. Therefore, we decided that the Plan has to pay for the laboratory panel provided on 
February 25, 2022, billed with code 0202U.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous infusion, refilling and maintenance of 
portable pump, and the office visit provided on June 19, 2023, by an OON provider.  
 
You asked the Plan to pay for the intravenous infusion, refilling and maintenance of portable pump, and the 
office visit. You say that you are appealing the denial with supporting documentation. The Plan denied your 
request. The Plan says the service was not authorized. 
 
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 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 pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the intravenous infusion, refilling and maintenance 
of portable pump, and the office visit provided on June 19, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a specialist visit. You say that you do not want to see any in-network 
providers. The Plan denied your request. The Plan says there are other providers available who are in-network, 
who are within the Medicare allowable distance from your residence. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) and pontics (D6240). 
 
You asked the Plan to pre-approve D6750 and D6240. You say that you have some rotten teeth and need this 
dental work. The Plan denied your request. The Plan says the requested dental services are not covered 
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. 
 
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 pre-approve a 
retainer crown (D6750) and pontics (D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion or replacement of a breast implant on a 
separate day from a mastectomy (19342) and a breast mastopexy (19316). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
  
 
 
The Plan follows Medicare rules. Medicare rules say that the removal of implant(s), whether placed for 
reconstructive or cosmetic purposes, will be considered medically reasonable and necessary for the treatment of 
any one or more of the indicated conditions. 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have breast implants. The record provided does not document the existence of an enumerated 
condition for which coverage is available under the Medicare rules. The elements of the coverage criteria are 
not satisfied. The requested services are not recommended. 
 
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 pre-approve the insertion or replacement of a breast implant on a separate day from a mastectomy 
(19342) and a breast mastopexy (19316).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a esophagogastroduodenoscopy to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve the esophagogastroduodenoscopy. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this service is 
available with in-network providers. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a esophagogastroduodenoscopy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on June 8, 2023. 
 
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that this was a routine eye examination. You also say that you had not received an eye 
examination for two years. The Plan denied your request. The Plan says this cost sharing for a medical eye 
examination (92014) was charged correctly. The Plan also says that a determination of refractive state (92015) 
is excluded from this benefit. 
 
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 $30 
copayment for a specialist office visit for a medical eye examination (92014).  
 
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 eye refractions only when they are apart of a routine eye examination. 
 
You have been asked to pay a $30 copayment for a medical eye examination (92014). This item/service falls 
within the specialist office visit 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. Also, the Plan rules also say a determination of refractive state (92015) is 
excluded from this benefit. The record shows this was not a routine eye examination and eye refraction, but a 
medical eye examination (92014) and a determination of refractive state (92015). Therefore, we decided that 
the Plan does not have to pay for a medical eye examination (92014) and a determination of refractive state 
(92015) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 98943, 97039-GP, G0283-GP, and 99214-
25 provided from February 8, 2023, to April 5, 2023. 
 
You asked the Plan to pay for procedure codes 98943, 97039-GP, G0283-GP, and 99214-25. You say that the 
medical records support the codes as billed.  The Plan denied your request. The Plan says the medical records 
do not support the codes as billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 98943, 97039-GP, G0283-GP, and 99214-
25. Our reviewer says that the medical records do not support the codes as billed.  Our reviewer found the 
documentation does not support the billing of codes 97039-GP and G0283-GP. The medical record submitted 
for review does not include a plan of care to include, at minimum: (1) diagnoses; (2) long-term treatment goals; 
and (3) type, amount, and duration of therapy services, as well as signed by treating physician.  
 
The provider reported procedure code 99214 with appended modifier 25 for a significant, separately 
identifiable evaluation and management (E/M) service above and beyond that associated with another 
procedure or service being reported by the same physician or other qualified health care professional (QHP) on 
the same date.  Although, medical record includes evaluation and management services, there is insufficient 
documentation to verify what procedure was performed, on the same date of service as the evaluation and 
management service. 
 
Additionally, procedure code 98943 has a status code of "N" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and is a non-covered service per Medicare guidelines. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 98943, 97039-GP, G0283-GP, and 99214-25 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 98943, 97039-GP, G0283-
GP, and 99214-25 provided from February 8, 2023, to April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service June 4, 2023. 
 
You asked the Plan to pay for procedure code 99051. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99051 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service June 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a calf rest/pad, replacement only (E0995). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says these are for replacement items. Calf pads are unbundled from the requested 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has been approved for a calf-rest pad. The records show that the calf pads are 
already included with the approved wheelchair. The calf pads cannot be requested separately. Therefore, we 
decided that the Plan does not have to pre-approve a calf rest/pad, replacement only (E0995).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the laboratory services provided on 
September 23, 2022, to February 17, 2023. 
 
You asked the Plan to waive the cost share for the lab service. You say that you have no control over the testing 
site. 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 40% of 
the total cost for out-of-network Medicare-covered outpatient lab services. Your contract with the Plan also 
clearly says that you must pay a $200 copayment for out-of-network Medicare-covered outpatient lab services. You have been asked to pay $62.64, which is 40% coinsurance of the allowed amount for the for the lab 
service provided on September 23, 2023. This item/service falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  
 
You have been asked to pay $156.59, which is less than the standard copayment for the lab services provided 
on February 17, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory services 
provided on September 23, 2022, to February 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a higher utilization of freestyle lite test strips (A4253). 
 
You asked the Plan to pre-approve a higher utilization of freestyle lite test strips (A4253). You say that the 
request for 300 test strips per 50 days is medically necessary. The Plan denied your request. The Plan says the 
request for 300 test strips per 50 days is not medically necessary. The plan approved 450 test strips per 90 days. 
 
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 a higher utilization of freestyle lite test 
strips (A4253). Our reviewer says that the request for 300 test strips per 50 days is not medically necessary. 
Our physician reviewer found the record indicates that the enrollee has diabetes. The record provided does not 
establish the need for the specific quantity of supplies that exceeds the usual utilization amount as enumerated 
in the rules. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 higher utilization of freestyle lite test strips (A4253) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a higher utilization of freestyle lite test strips 
(A4253).