Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 26, 2022, to 
July 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claims were submitted 
correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 26, 2022, to July 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography provided on December 16, 2022.  
You asked the Plan to pay for the fundus photography. You say that you are appealing the denied charge for the 
fundus photography. 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 does not cover this service as a part of the supplemental benefits. 
 
We looked at the file and the Plan's rules. Specifically, the fundus photography was billed with a routine vision 
diagnosis of disorders of refraction and accommodation. Based on this information, we decided that the Plan's 
rules for coverage of the fundus photography have not been met. Therefore, we decided that the Plan does not 
have to pay for the fundus photography provided on December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medication Lumigan Sol 0.01%. 
 
You asked the Plan to pre-approve the medication Lumigan Sol 0.01%. 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 the medication Lumigan Sol 
0.01%.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 October 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service October 9, 
2022, to October 20, 2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service October 9, 2022, to October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says that the requested service is not medically necessary as Medicare criteria have not been 
met. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in  and benefit from  the intensive rehabilitation therapy program provided in 
an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as G0103, 85025, 84443, 
83036, 82306, 80061, 80053 and 86415 provided on September 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 laboratory services coded as G0103, 85025, 
84443, 83036, 82306, 80061, 80053 and 86415 provided on September 16, 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the equipment to be 
discharged and does not feel that the medical equipment should be returned. The Plan denied your request. The 
Plan says the records do not show that the enrollee failed BiPap therapy while hospitalized. The enrollee was 
treated with BiPap, and records indicate her breathing improved. The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on January 5, 2023, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 outpatient visit provided on January 5, 2023, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 29, 2022, billed with 
codes 87481, 84791, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 
87798. 
 
You asked the Plan to pay for the testing billed. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that A panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 We looked at the file and Medicare rules. This service was a panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on September 
29, 2022, billed with codes 87481, 84791, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 
87653, 87661, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual nursing facility assessment provided on  
September 16, 2022. 
 
You asked the Plan to pay for the annual nursing facility assessment. You say that the services were medically 
necessary. The Plan denied your request. The Plan says in the absence of clinical information, medical 
necessity and coverage cannot be determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the annual nursing facility assessment 
have been met. Therefore, we decided that the Plan does not have to pay for an annual nursing facility 
assessment provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that there was a coding error made on the claim. The 
Plan denied your request. The Plan says you got the services from a provider who chose not to receive 
Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on March 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to March 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claims have been submitted 
correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022, to 
March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (87426) provided on January 5, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that your spouse's claim was covered. The Plan 
denied your request. The Plan says the provider who rendered the services does not participate in Medicare, 
and therefore the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 testing (87426) provided on January 5, 2021.  
 Your complaint about a potential discrepancy in how your claim was handled versus how your spouses claim 
was handled 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 pay for the genetic testing provided on January 17, 2023, billed with 
codes 87481, 87500, 87640, 87652, 87798 x13, 87798-91 x8, 87799, 87900. 
 You asked the Plan to pay for the genetic testing billed. You say that you have included additional documents 
for review and are requesting the claim be reconsidered for payment. The Plan denied your request. The Plan 
says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 17, 2023, billed with codes 87481, 87500, 87640, 87652, 87798 x13, 87798-91 x8, 87799, 87900.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services on August 11, 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 that the services are not medically necessary. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the documentation provided meets the criteria 
of medically reasonable and necessary for coverage for D7953 and D4266 to preserve and restore alveolar bone 
in area #19. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pay for the dental services on August 11, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable electric wheelchair. 
 
You asked the Plan to pre-approve a foldable electric wheelchair. You say that you need a foldable wheelchair 
to fit in your car to go shopping. The Plan denied your request. The Plan says that the requested wheelchair 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 foldable electric wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation provided on November 15, 2022. 
 
You asked the Plan to pay for the ophthalmological services: medical examination and evaluation. You say that 
this service is a covered benefit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. At the time of the claim processing the member had met $143.94 of her $290 annual deductible. The 
claim processed correctly, and the member is responsible for the full amount of $102.46. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $290 deductible which applies to vision services.  
 
The service you asked the Plan to pay for falls within the vision services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible which applies to 
vision services. This cost sharing is a contractual obligation that had not been met at the time the 
ophthalmological services: medical examination and evaluation was received on November 15, 2022. Therefore, we decided that the Plan does not have to pay for ophthalmological services: medical examination 
and evaluation provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99349), debridement of devitalized tissue from wounds (11043), chemical cauterization of 
granulation tissue (17250), and debridement, muscle and/or fascia (11046) provided on November 13, 2022, by 
an out-of-network (OON) provider. 
 You asked the Plan to pay for the home health services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the home visit for the evaluation and management of an established patient 
(99349), debridement of devitalized tissue from wounds (11043), chemical cauterization of granulation tissue 
(17250), and debridement, muscle and/or fascia (11046) provided on November 13, 2022, by an out-of-
network (OON) provider.