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

 
We decided that the Plan does not have to pay for physician's services provided on October 23, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from out-of-network providers are not covered unless they are preauthorized. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the non-emergent transportation services. You say that you would like 
reconsideration because the services rendered were medically necessary. The Plan denied your request. The 
Plan says these services can be rendered in-network. 
 
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 January 28, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services you received on July 15, 2020. 
 
You asked the Plan to waive the deductible for the lab services. You say that you have never had to pay this 
deductible before, so you aren't going to pay it now. The Plan denied your request. The Plan says this 
deductible was assessed correctly.  You had not yet met your deductible at the time of the lab services. 
 
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 $250 deductible for laboratory tests.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for 
laboratory tests. This cost sharing is a contractual obligation that had not been met at the time the lab services 
were received on July 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
lab services you received on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 24, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physician's services. 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 physician's services provided on February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physician's services. 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 physician's services provided on April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 3, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you do not require additional authorization 
due to the fact that you do not see patients and you are considered a "hidden/blind provider". The Plan denied 
your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the referring physician in this case are not network providers with the Plan. The 
Plan did not pre-approve the laboratory services. 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 laboratory services provided on 
October 3, 2019.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of diabetes and coronary artery disease who presented to the acute hospital on 10/05/2020 for a 
scheduled coronary artery bypass surgery. The surgery had to be delayed due to hypotension. The bypass 
procedure was eventually cancelled due to labile blood pressure and percutaneous coronary interventions were 
scheduled instead. He was also treated for a gout flare and urinary retention and hematuria while in the 
hospital. He is weak and deconditioned and is working with physical and occupational therapy. He is walking 
90 feet with a walker with minimal assistance and is minimal to moderate assist for transfers and activities of 
daily living. His therapy is reported to be limited by fatigue, decreased endurance and short term memory 
deficits and the need for cueing. It is noted that he is only able to follow single step instructions. He is reported 
to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cialis (J8499). 
 
You asked the Plan to pre-approve Cialis. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 Cialis (J8499).  
 
Benefits for Cialis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
May 29, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that your doctor advised you to go to the 
ER due to a blood test result.  When you got to the ER, you checked in and called your doctor again, who then 
advised you that the ER visit wasn't necessary.  You say that since you left the ER and didn't see a doctor, you 
should not have to pay a copayment. The Plan denied your request. The Plan says you were assessed this 
copayment correctly.  The Plan says that since the allowed amount is less than your $75 copayment, you are 
responsible for the full 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 $75 
copayment for emergency room services.  
 
You have been asked to pay a $75 copayment for the ER visit. This copayment applies even though you did not 
have a full work-up at the ER.  Medical records show that you were triaged and ER staff took your vital signs 
(height, weight, temperature, pulse, oxygen level, and blood pressure).  You did receive ER services, so 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 emergency room (ER) visit you had on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the panoramic x-ray (D0330) provided on
July 23, 2020.
You asked the Plan to waive the coinsurance for the dental service. You say that you assumed the x-ray would
be covered. You say that you thought the x-ray was part of your cleaning. You also say that the provider did
not explain that the service would be billed separately or ask. The Plan denied your request. The Plan says
panoramic x-rays have a 50% coinsurance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and panoramic x-rays are listed, there is
a 50% coinsurance for basic services. This is a contractual obligation you agreed to when you enrolled in the
Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the coinsurance for the
panoramic x-ray (D0330) provided on July 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 19, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $225 copayment charged to the enrollee for ambulance 
transport on April 9, 2020. 
 
You asked the Plan to waive this copayment. You say that this transport copayment should be waived due to 
Covid-19. The Plan denied your request. The Plan says this copayment was charged based on the services 
provided and the Plan contract agreement. 
 
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 contract with the Plan clearly says that enrollees must pay $225 
copayment for ambulance transport. The enrollee has been asked to pay the correct amount based on the 
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 $225 copayment charged to the enrollee 
for ambulance transport on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab work provided by a participating 
provider on July 14. 2020. 
 
You asked the Plan to waive the deductible for lab work. You say that this was lab work provided during your 
annual wellness exam. You say that you have never had to pay for this service before. The Plan denied your 
request. The Plan says the correct deductible amount has been applied. 
 
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 $250 deductible for outpatient diagnostic tests/laboratory tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests/laboratory tests. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $250 deductible for outpatient diagnostic tests/laboratory tests. The total amount you are being asked 
to pay is $127.24. This cost sharing is a contractual obligation that had not been met at the time lab work was 
received on July 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for lab 
work provided by a participating provider on July 14. 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided on January 6, 
2020. 
 
You asked the Plan to pay for the non-emergent ambulance transport. The Plan denied your request. The Plan 
says the services were not authorized and could have been provided with an in-network provider. 
 
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 did not pre-approve the 
services 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 non-emergent ambulance transport provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 and the referring provider in this case are not network providers with the Plan. The Plan 
did not pre-approve the laboratory services. 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 laboratory services provided on May 22, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT of the abdomen and pelvis (74176) provided on May 26, 
2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this service 
denied as a duplicate in error. The Plan denied your request. The Plan says services that are considered column 
II procedures to another service are not eligible for reimbursement when billed with the column I procedure 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the CT 
Scan has a bundled relationship with code 74174 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for CT of the abdomen and pelvis (74176) provided on May 26, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid evaluation provided on July 13, 2020. 
 
You asked the Plan to pay for this service. You say that you believed this visit and hearing aid evaluation 
would be covered. The Plan denied your request. The Plan says additional visits are not covered under the 
supplemental hearing benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids from a specific provider and only pays for limited visits. The hearing aid evaluation or conformity 
evaluation provided on July 13, 2020 are not part of your covered benefit. Therefore, we decided that the Plan 
does not have to pay for a hearing aid evaluation provided on July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) 
provided on June 4, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $250 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $250 copayment for the Medicare-covered diagnostic colonoscopy provided in 
an outpatient hospital facility. A diagnostic colonoscopy is performed in order to explain symptoms identified 
by your physician. The record shows that your pre-operative diagnosis included potential symptoms of colon 
cancer. 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 diagnostic colonoscopy (45378) provided 
on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physician's services. 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 physician's services provided on June 4, 2020.