Persius/hicric huggingface dataset:
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 very sick, and you needed to go to the hospital. You say that you called for an ambulance as well as your daughter. You stated that you were advised by the emergency responders that you could save money if you were driven to the hospital by your daughter. You say that your daughter ended up taking you to the hospital and now the Plan has denied coverage for the ambulance services because you were not transported. You stated that you want to appeal the Plan's denial since the Plan would have paid for the services if you were advised differently by the ambulance staff. You say that you do not believe that you should be responsible for the cost and you asked the Plan to reconsider providing coverage. 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 December 18, 2019. 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: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on April 2, 2020.
You asked the Plan to waive the copay for the ambulance transport. You say that you did not have an ambulance ride. The Plan denied your request. The Plan says that you have a $250 copay per Medicare covered ground ambulance trip.
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 copay for ground ambulance services. You have been asked to pay a $16.75 copay for the ambulance transport. The ambulance transport falls within the ground ambulance services benefit category. This means that you have been asked to pay less than 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 transport provided on April 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
11, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The 
Plan says that the copayment 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 $200 
copayment per date of service regardless of the number of ground ambulance trips.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 
within the per date of service regardless of the number of ground ambulance trips 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 ambulance transport provided on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head (70450) provided 
March 30, 2020. 
 
You asked the Plan to pay for the CT reading. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the CPT code billed shares a Column I / Column II relationship with 
another code billed. 
 
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 70450 
has a Column I/ Column II relationship with code 70496 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 computed tomography (CT) of the head (70450) provided 
March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and radiology services provided by a 
chiropractor on November 27, 2019. 
 
You asked the Plan to pay for the services provided. You say that the services should be covered. The Plan 
denied your request. The Plan says only manual manipulation of the spine to correct a subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit and radiology services provided by a chiropractor on 
November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided to the 
enrollee on March 1, 2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says sufficient information was not provided from 
the provider as evidenced by a lack of recent oxygen (O2) prescription, recent oximetry test, or updates on the 
status of the O2 therapy use. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the oxygen concentrator have not been met. Review of the file 
shows the most recent oxygen saturation rate testing that was provided was back on February 13, 2001 at rate 
of 86%. No additional information was provided to support a more recent o2 sat rate and the MD order is 
approximately 10 months old. Therefore, we decided that the Plan does not have to pay for oxygen 
concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the 
prescribed flow rate (E1390) provided to the enrollee on March 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two replacements of semi-precision or precision attachments, implant maintenance procedures, and problem focused limited oral evaluation provided on February 20, 2020 by an OON provider.
You asked the Plan to pay for the replacements of semi-precision or precision attachments, implant maintenance procedures, and problem focused limited oral evaluation. You say that you do not understand why this claim cannot be paid. The Plan denied your request. The Plan says the replacements of semi-precision or precision attachments and implant maintenance procedures are not covered benefits. The Plan also says that the charges for the problem focused limited oral evaluation exceed the allowable amount.
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, implant services are not among those covered under this benefit. The contract also clearly states that you will be responsible for the full amount by which the actual charges of an out-of-network dentist exceed the allowable charge. Therefore, we decided that the Plan does not have to pay for the two replacements of semi-precision or precision attachments, implant maintenance procedures, and problem focused limited oral evaluation provided on February 20, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 2, 2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 code G0482 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records stating exactly what 
tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
G0482 provided on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the outpatient knee replacement procedure and 
hospital services provided from March 19, 2020 to March 20, 2020. 
 
You asked the Plan to waive the charges for the outpatient hospital care. You say that you were in the hospital 
for 30 hours. You believe that no one would consider that outpatient care and that this should be re-billed as 
inpatient. The Plan denied your request. The Plan says you received outpatient surgery for which the correct 
cost sharing 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 $350 
copayment for outpatient surgery provided in a hospital. It is noted that you may stay overnight and still be 
considered an outpatient. 
 
You have been asked to pay a $350 copayment for the outpatient hospital care. The services provided fall 
within the outpatient surgery provided in a hospital 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 
charges for the outpatient knee replacement procedure and hospital services provided from March 19, 2020 to 
March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) rendered by the out of network 
(OON) provider on February 27, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99212) rendered by the out of network (OON) provider on February 27, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing services provided by an out-of-network provider on December 13, 2018.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained.
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 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 failed to provide a 2018 EOC and additional information that was needed to determine a decision. Therefore, we decided that the Plan has to pay for skilled nursing services provided by an out-of-network provider on December 13, 2018.
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90792). 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the provider does not participate in Medicare and 
therefore is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services (90792).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 13, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not go to this 
appointment and therefore do not owe anything for the visit. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $30 
copayment for a specialty physician.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls 
within the ?Physician/Practitioner services, including doctor?s office visits? benefit category. The medical 
record shows you were seen for a consultation for evaluation of urinary incontinence on January 13, 2020. 
 
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 specialist office visit provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a 
participating provider on April 14, 2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were told that you would 
not have a copayment. The Plan denied your request. The Plan says the correct copayment has 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay a $65 copayment for an urgent care visit. The correct copayment has been applied 
to the services provided. An urgent care visit falls within the urgently needed 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 urgent care visit provided by a participating provider on 
April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) provided on October 2, 2019. 
 
You asked the Plan to pay for the extraction. You say that this service was necessary. The Plan denied your 
request. The Plan says this service is not covered by the Plan. 
 
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 the 
extraction (D7210) provided on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 29, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
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 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on 
January 7, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the services billed. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
The CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician 
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in 
addition to code for primary service). 
 
We find that CPT codes 99152 and 99153 are not supported in the record. Specifically, the record does not 
indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage 
of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay 
for moderate sedation services (99152 and 99153) provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 10, 2018 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services. 
 
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 skilled nursing services provided on December 10, 
2018 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 13, 2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 code G0482 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0482 provided on August 13, 2019.