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

 
We decided that the Plan does not have to fully reimburse you for the prophylaxis and periodic oral evaluation 
provided on May 15, 2019. 
 
You asked the Plan to fully reimburse you for the prophylaxis and periodic oral evaluation. You say that you 
paid in full for the dental services. You say that you should be fully reimbursed. The Plan denied your request. 
The Plan says payment was issued to the provider for the prophylaxis and you were reimbursed for the oral 
evaluation. 
 
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. 
 
The records show that the Plan paid the provider for the prophylaxis. This means that the dental office is 
responsible for issuing a refund for the prophylaxis. Therefore, we decided that the Plan does not have to fully 
reimburse you for the prophylaxis and periodic oral evaluation provided on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on November 26, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urinary catheters (A4352) provided on 
February 4, 2020. 
 
You asked the Plan to waive the coinsurance for urinary catheters. You say that you were informed by a 
representative of the Plan that you could receive urinary catheters at no cost to yourself. The Plan denied your 
request. The Plan says the correct coinsurance was 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 20% 
coinsurance for Medicare-covered Durable Medical Equipment (DME) items.  
 
You have been asked to pay $209.55 or 20% of the Plan's allowed cost of $1,047.75 for urinary catheters. 
Urinary catheters fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for urinary catheters (A4352) provided on February 4, 2020.  
 
Your complaint about a representative of the Plan providing you with erroneous or misleading information 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services (A0431) provided November 27, 
2019. 
 
You asked the Plan to pay for the air ambulance services. You say that the air ambulance transport was 
medically necessary. The Plan denied your request. The Plan says the enrollee was stable for ground transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that air transportation was not medically necessary. Our physician reviewer found documentation did not 
support that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the 
instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the 
enrollee's health. Ground transport would have taken 30 minutes or less. 
 
 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services (A0431) provided November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for portable X-Ray examination. You say that you do not have ample time to verify 
eligibility and request authorization before service. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because this provider is out-of-network with the Plan and the referring 
provider is also out-of-network with the Plan. 
 
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 December 11, 
2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you do not think you have to pay this charge. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 7, 
2019 to November 13, 2019 and from November 21, 2019 to November 22, 2019. 
 
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 DRG on the claim cannot be priced as submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed correctly and the DRG 
cannot be priced as billed. The Plan has requested a corrected claim for these services. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital services rendered from November 7, 2019 to 
November 13, 2019 and from November 21, 2019 to November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 1, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation shows presumptive and definitive drug testing was provided. We looked at the file and the 
rules. Medicare rules say that providers must produce medical records showing why the lab services provided 
were medically necessary. In this case, there were insufficient records that show the testing was individualized 
to identify specific non-prescribed medications or illicit substances. The records provided do not document 
concerns based on clinical review and judgement. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. This testing is performed on a blood sample. The records provided do not indicate a blood sample was 
obtained for the testing services at issue. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 28, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation does not 
support that these tests were ordered by the enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services. The rules say that laboratory testing must be ordered by the 
physician who is treating the enrollee for a specific medical problem and who uses the results in the 
management of the enrollee's specific medical problem. 
 
We looked at the file and Medicare rules. The documentation does not support that these tests were ordered by 
the enrollee's treating physician. Therefore, the documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were eating dinner when you passed out because your sugar levels dropped very low. Your family called for an ambulance and when the responders arrived, they successfully treated you with an IV. You say that you did not need further treatment because your condition had stabilized. You stated that you did not want to go to the hospital because of the risk of exposure to Covid-19. You say that you did not want to incur additional medical bills for no reason, and you asked the Plan to reconsider providing coverage for the services. 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 April 2, 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.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation provided on April 6, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that this was ambulance transportation to the 
hospital. The Plan denied your request. The Plan says that the denial of payment for this service is correct, 
because you requested to be transported to this destination and this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say that ambulance transportation may be covered by Medicare if it meets certain origin 
and destination requirements. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied payment on the basis that the destination for this 
transportation is not covered by Medicare. No medical records were submitted to support the origin and 
destination of this ambulance transportation. Furthermore, no documented attempts to obtain such records were 
submitted for review. The Plan claims that additional information from the ambulance provider shows you 
requested to be transported to a hospital other than the nearest hospital, however this information was not 
submitted for review. Without supporting information, the Plan has not shown that its decision to deny 
payment for this ambulance transportation is correct or justified according to Medicare rules. Therefore, we 
decided that the Plan has to pay for ambulance transportation provided on April 6, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on December 11
2019. 
 
You asked the Plan to pay for the bone replacement graft. You say that you would like reconsideration because 
this service was rendered in-network. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80157, 80159, 80162, 80173, 80177, 
80201, 80307, and G0483) provided on December 23, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. The record did not include a physician order/lab requisition 
or medical records stating exactly what tests are to be performed. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (80157, 80159, 80162, 80173, 80177, 80201, 80307, and G0483) 
provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0483, 80157, 80177, 80201, 80162, 
80159 and 80173) provided January 30, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says the submitted Laboratory Requisition 
indicates that a Chronic Care Management Profile Panel was requested. The submitted documentation does not 
itemize what tests are included in this panel. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. The record did not include a physician order/lab requisition 
or medical records stating exactly what tests are to be performed. Therefore, we decided that the Plan does not 
have to pay for laboratory services (G0483, 80157, 80177, 80201, 80162, 80159 and 80173) provided January 
30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0427) 
provided April 18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was 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 $200 
copayment for Ambulance Services.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance Services 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 
an ambulance transport (A0425, A0427) provided April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided from September 17, 2019 to 
November 6, 2019. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says the provider is not 
in-network and there is no authorization on file. 
 
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 
home visit. 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 a home visit provided from September 17, 2019 to November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a debridement of skin and tissue (11042) 
performed on March 4, 2020. 
 
You asked the Plan to waive the copayment for a debridement of skin and tissue. You say that you did not 
receive hospital services and the assessed copayment is an error. The Plan denied your request. The Plan says 
the correct copayment was 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 each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or 
ambulatory surgical center. 
 
You have been asked to pay a $150 copayment for a debridement of skin and tissue. A representative of the 
provider confirmed that you received this service at an outpatient surgery center. A debridement of skin and 
tissue falls within the Outpatient surgery 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 debridement of skin and tissue (11042) performed on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the immunotherapy injections (95117) 
provided on January 27, 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $10.36 copayment for the injections provided at a specialist office visit. This is 
the Plan allowed amount which is less than the applicable copayment. 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 immunotherapy injections (95117) provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopathy services received from February 1, 2020 to 
March 16, 2020. 
 
You asked the Plan to pay for the services. You say that you would like to have your visit maximum 
accumulator reset to only show that you used two visits for the calendar year. The Plan denied your request. 
The Plan says the claims were processed appropriately. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan pays for the 
services of a naturopath only for 18 visits per year.  
 
You are requesting that your benefit to be adjusted so that it only shows that you used two naturopathy visits. 
The plan reprocessed some of the office visits where you did not see the doctor, but the claims were otherwise 
processed appropriately. Your benefit correctly shows that you have used seven naturopathy visits. You are 
allowed a total of 18 per year. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for naturopathy services 
received from February 1, 2020 to March 16, 2020.