Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791). 

You asked the Plan to pay for integrated biopsychosocial assessment. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for integrated biopsychosocial assessment was not filed until October 12, 2020.. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427, A0425) billed for October 29, 
2020. 
 
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your 
request. The Plan says the records do not support this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A0427 and A0425 is not supported in the medical record. Specifically, the records do 
not show that ambulance services were provided on October 29, 2020. The records show these services being 
performed on October 28, 2020. Based on this information, we decided that Medicare rules for coverage of 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services (A0427, A0425) billed for October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) 
provided September 29, 2020. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were 
medically necessary. The Plan denied your request. The Plan says the medical records do not support services 
provided. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis and suspension sleeve are subject to 
the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our 
reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there 
is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible 
objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable 
when the base item is not covered. 
 
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 knee orthosis and suspension sleeve have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) 
provided September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place then 
triaged to BLS. 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 22, 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 April 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided from July 7, 2019, to July 
15, 2019. 
 
You asked the Plan to pay for the services provided. You say that the loss of revenue will be devastating for the 
clinic. The Plan denied your request. The Plan says the claims were received past the allowed timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until July 27, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the physician services provided from July 7, 2019, to July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the flu vaccine provided on October 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that no prior authorization was needed. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 had network providers available to provide the services at issue in this appeal. 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 the flu vaccine provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayment for the colonoscopy.

You asked the Plan to reimburse you the copayment for the colonoscopy. You say that this was a preventative service. 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 $325 copayment for Outpatient Surgery at an outpatient hospital facility.

You have been asked to pay a $325 copayment for the colonoscopy. the colonoscopy falls within the Outpatient Surgery at an outpatient hospital facility benefit category. The provider submitted the claim as a diagnostic colonoscopy. 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 reimburse you the copayment for the colonoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you were not advised this service was not covered. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 this device. Our reviewer says that Medicare coverage criteria are not met. 
Our physician reviewer found the medical records do not show the enrollee is using insulin multiple times (3 or 
more) a day and her treatment does not require frequent adjustment on the basis of testing results. Medicare 
coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided 
on August 7, 2020. 
 
You asked the Plan to waive the copay for the transportation services. You say that you were admitted into the 
hospital. The Plan denied your request. The Plan says your hospital stay was authorized as observation care 
only. 
 
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 $300 
copay for Medicare-covered one-way ambulance benefit per segment. for ambulance services.  
 
You have been asked to pay a $300 copay for the transportation services. The services fall within the 
ambulance services benefit category. The records do not indicate that you were admitted as an inpatient for 
hospital services. 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 copay for the ambulance transportation services 
provided on August 7, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on September 3, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because 
your provider cannot deny medical services that are essential to the member's treatment. The Plan denied your 
request. The Plan says utilization of network providers is required unless the care is pre-approved by the Plan 
in non-emergent situations. 
 
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 nursing facility care provided on September 3, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided to the enrollee on July 28, 2020. 
 
You asked the Plan to pay for a crown (D2740). You say that this dental crown was necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a crown (D2740). 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found due to the lack of proper and required documentation to determine 
coverage for a crown, the criteria for coverage have not been met. 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 crown 
(D2740) have not been met. Therefore, we decided that the Plan does not have to pay for a crown (D2740) 
provided to the enrollee on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services.

You asked the Plan to pay for the services provided. You say that at the time of service, the enrollee provided Medicare insurance information. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services provided was not filed until November 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01480 provided on November 
19, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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, the CPT Code Manual definition of code 01480 is anesthesia for open procedures on bones of 
lower leg, ankle, and foot; not otherwise specified. 
 
We find that CPT code 01480 is not supported in the medical record. Specifically, this code was billed with 
primary diagnoses of M10.472 (other secondary gout, left ankle and foot) and F32.9 (major Depressive 
Disorder, Single Episode, Unspecified). M10.472 cannot be listed as a primary diagnosis for this code. Based 
on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01480 provided on 
November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy procedure (45378, 45380, 
45381) provided December 11, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were told you had no copay. 
The doctor?s office called the plan and was told there would be $0 copay if nothing was found and $320 if 
polyps were found. You would not have had the colonoscopy if you had to pay. The Plan denied your request. 
The Plan says the claim was processed and the correct copayment applied per the Evidence of Coverage. 
 
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 
copay per visit for Medicare covered services in an ambulatory surgical center.  
 
You have been asked to pay $250 copay for the colonoscopy. The colonoscopy falls within the Outpatient 
surgery, including services 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 copayment for the colonoscopy procedure (45378, 45380, 
45381) provided December 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place and 
triaged to BLS. 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 23, 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 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
September 6, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the plan requires the utilization of in-network providers unless the Plan pre-approves out-of-network services in 
non-emergent situations. Authorization for out-of-network services 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 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 subsequent nursing facility care provided on September 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services (47000, 77012, 88305, 88112, 86901, 85025, 80053, 83735, 84100, 85610, 85730, 86850, 99241, G0462, 86900, 86921, 93000, 71046, 81002, 88108) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON oncology services. You say that the enrollee's oncologist would like him to have biopsies performed by the requested provider. The Plan denied your request. The Plan says these services are available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve oncology services (47000, 77012, 88305, 88112, 86901, 85025, 80053, 83735, 84100, 85610, 85730, 86850, 99241, G0462, 86900, 86921, 93000, 71046, 81002, 88108) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
November 6, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 a domiciliary or rest home visit provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit and electrocardiogram 
provided on June 6, 2019. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed 
untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit and electrocardiogram was not filed until 
August 27, 2020. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit 
and electrocardiogram provided on June 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place and 
triaged to BLS. 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 4, 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 4, 2020.