Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test and an ECG provided by a 
participating provider on March 6, 2020. 
 
You asked the Plan to waive the copayment for a stress test and an ECG. You say that you thought you didn't 
have to pay for the stress test. The Plan denied your request. The Plan says the correct copayments have been 
applied. 
 
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 $150 
copayment for outpatient diagnostic tests/advanced imaging services and a $10 copayment for outpatient 
diagnostic tests/diagnostic tests.  
 
You have been asked to pay a $150 copayment for a stress test and a $10 copayment for an ECG. The total 
amount you are being asked to pay is $160 ($150 + $10 = $160). A stress test falls within the outpatient 
diagnostic tests/advanced imaging services benefit category and an ECG falls within the outpatient diagnostic 
tests/diagnostic tests 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 a stress test and an 
ECG provided by a participating provider on March 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 23, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not remember being 
put in an ambulance for this transport from hospital to helipad. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ambulance services on May 23, 2020. You pay a $325 copayment for 
the ambulance services. Your EOC states that enrollees must pay a $325 copayment for Medicare-covered 
ambulance services per trip. 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 ambulance services 
provided on May 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 20, 2020. 
 
You asked the Plan to waive the copayment for the emergency care. You say that you felt nothing was done in 
the emergency department. The Plan denied your request. The Plan says you were charged this copayment 
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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for the emergency care. the emergency care falls within the 
Emergency 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 emergency care 
provided on September 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for intravenous infusion therapy provided 
from July 27, 2020, to August 17, 2020. 
 
You asked the Plan to waive the copayments for intravenous infusion therapy. You say that you disagree with 
the charges and feel they are too high. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct amount. 
 
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 $265 
copayment for outpatient surgery and other medical services and provided at hospital outpatient facilities.  
 
You received intravenous infusion therapy from July 27, 2020, to August 17, 2020, for a total of 5 visits. 
Therefore, you are responsible to pay the total allowed amount of $986.70.  
 
You have been asked to pay the total copayment amount of $986.70 for intravenous infusion therapy. 
Intravenous infusion therapy falls within the outpatient surgery and other medical services and provided at 
hospital outpatient facilities and ambulatory surgical centers 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 copayments for intravenous infusion therapy provided from July 27, 2020, to August 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation and an 
emergency room visit provided on July 30, 2020. 
 
You asked the Plan to waive the copayments for ambulance transport and emergency room visit. You say that 
these services happened while you were asleep, so you do not feel it is your responsibility to pay. The Plan 
denied your request. The Plan says the copayment amounts you are being charged are correct. 
 
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 $250 
copayment for ambulance transport and $90 copayment for emergency room visit. Your total copayment 
obligation is therefore $340.  
 
You have been asked to pay $250 copayment for ambulance transport and $90 copayment for emergency room 
visit. Ambulance transport and emergency room visit fall within the "Ambulance Services" and "Emergency 
Care" benefit categories. 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 copayments for ambulance transportation 
and an emergency room visit provided on July 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) provided 
on February 14, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you shouldn't be 
charged because you could have gone to the radiology department. The Plan denied your request. The Plan says 
this processed 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 $120 
copayment for emergency room visits.  
 
You have been asked to pay a $120 copayment for an emergency room visit. 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 an emergency room visit (99285) provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (E1399) 
 
You asked the Plan to pre-approve a scooter. You say that you have anemia. The Plan denied your request. The 
Plan says your records show no reason for the wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a scooter (E1399)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood flow stimulation wrap with electrical stimulation 
and ice packs. 
 
You asked the Plan to pre-approve blood flow stimulation wrap with electrical stimulation and ice packs. You 
say that you have poor blood flow and the doctor recommends you get this. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules say that health plans must pay for a medical service or item if regular Medicare would pay for 
it. (42 CFR 422.101) 
 
The requested Durable Medical Equipment does not meet the Medicare criteria of Durable Medical Equipment 
per NCD 280.1, and the manufacturer of the particular brand the member mentions finding online is not a Medicare provider. Ice packs can be provided through the Over-the Counter (OTC) benefits of the 
Health plan. Therefore, we decided that the Plan does not have to pre-approve blood flow stimulation wrap 
with electrical stimulation and ice packs.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on August 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not bil led with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove an ultralight custom motorized wheelchair (K0008). 
 
You asked the Plan to preapprove an ultralight custom power wheelchair. You say that you want the extra 
lightweight custom wheelchair. The Plan denied your request. The Plan says you already have similar 
equipment and there isnt a need for the ultra lightweight wheelchair.  
 
The Plan must follow Medicare rules. Rules say that you must meet a standard of criteria to get the custom 
ultra lightweight motorized wheelchair. A contact with your provider confirms that the enrollee does not have 
any clinical or physical changes that preclude the use of current DME and that she needs the replacement of 
custom powered equipment. Therefore, we decided that the Plan does not have to preapprove an ultralight 
custom motorized wheelchair (K0008).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 25, 2020, to 
July 24, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 25, 2020, to July 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 28, 2020 by a non-
participating provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on May 28, 2020 by 
a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0429) provided on March 26, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed per CMS 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that in the case where the beneficiary was pronounced dead after the ambulance is called CPT 
code A0428 must be reported with the QL and QM or QN modifier. 
 
We find that CPT code A0429 is not supported in the record. Specifically, the record indicates that the member 
was pronounced dead after the ambulance was called. This service was not reported with an appropriate CPT 
code and required modifier. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services (A0429) provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on July 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. 
 
In this case, you billed assistant surgery services for CPT codes 19340 and 19371. The Medicare Fee Schedule 
Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that 
an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that 
Medicare coverage criteria for these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the assistant surgeon services rendered on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services rendered on March 
19, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you shouldn't be liable. The Plan 
denied your request. The Plan says the copayment was applied 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 $65 
copayment for Medicare-covered urgently needed care visits.  
 
Review of the file shows that you received urgent care services on March 19, 2020. You have been asked to 
pay a $65 copayment for these services. These services fall within the Medicare-covered urgently needed care 
visits 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 the urgent care services rendered 
on March 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 30, 2020, to 
June 10, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from May 30, 2020, to June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a custom manual wheelchair (K0005, K0739). 
 
You asked the Plan to preapprove a custom wheelchair. You say that the manual wheelchair the enrollee has 
broke, and they require a new one. The Plan denied your request. The Plan says a custom wheelchair is not 
indicated. An assessment for repair vs. replacement of a standard manual wheelchair is required. 
 
The Plan follows Medicare rules. Medicare rules say that the requested custom manual wheelchair is not 
indicated, rather, a repair versus replacement comparison quote of her basic manual wheelchair is indicated to 
determine the most cost-effective option as a basic manual wheelchair is appropriate to meet her mobility 
needs. The enrollee does not meet the requirements with special features or had a specialty evaluation.  
Therefore, we decided that the Plan does not have to preapprove a custom manual wheelchair (K0005, K0739).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug test (80307), comprehensive metabolic panel (80053), lipid panel (80061), and thyroid stimulating hormone assay (84443) provided on June 19, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe drug test, comprehensive metabolic panel, lipid panel, and thyroid stimulating hormone assay provided by an OON provider. You say that the services werenecessary.The Plan denied your request. The Plan says the services were obtained from an out-of-network provider without prior authorization, therefore coverage criteria has not been met.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 has network providers available who can provide 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 forthe drug test (80307), comprehensive metabolic panel (80053), lipid panel (80061), and thyroid stimulating hormone assay (84443) provided on June 19, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab). 
 
You asked the Plan to pre-approve Pembrolizumab. You say that Pembrolizumab is a promising and reasonable 
treatment option to continue for this enrollee. The Plan denied your request. The Plan says the medical criteria 
has not been met, and this treatment is not considered reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab. Our reviewer says that 
Pembrolizumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found there 
is no compendia basis or literature support for Keytruda and Rituxan in central nervous system lymphoma. Our 
reviewer also found that this drug is not Food and Drug Administration approved for this indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Keytruda (Pembrolizumab).