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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
3, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you are not liable 
for these services. The Plan denied your request. The Plan says the claim has been processed correctly per your 
plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
Your copayment requirement for ambulance services is $250. However, the allowed amount for this service 
was $230.74. Since this is less than your $250 copayment requirement, you were charged the lesser amount. 
 
You have been asked to pay a $230.74 copayment for the ambulance services. the ambulance services fall 
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 the 
ambulance services provided on April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injections you received on 
March 1120, 2020 through April 15, 2020. 
 
You asked the Plan to waive the coinsurance for the aflibercept injections. You say that you were not aware of 
the coinsurance prior to receiving services. The Plan denied your request. The Plan says you were charged this 
coinsurance appropriately. 
 
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 Part B covered drugs.  
 
You have been asked to pay 20% coinsurance for the aflibercept injections. The aflibercept injections fall 
within the Medicare Part B covered drugs 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 the aflibercept injections you received on March 1120, 2020 through April 15, 2020.  
 
Your complaint about not being told that this drug was much more expensive than the drug you had been 
taking previous 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 ALS 2 ambulance service (A0433B) and unlisted ambulance 
service (A0999B) provided January 13, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that please read narrative explaining why you 
did not transport. The enrollee was not breathing and was not able to be resuscitated. The coroner took the 
enrollee. The Plan denied your request. The Plan says the procedure code is inconsistent with the modifier 
used. Reimbursement is only appropriate for a BLS service, HCPCS code A0428, reported with modifier QL. 
A corrected claim can be submitted. 
 
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 A0433 is advanced life support, level 2 ambulance 
service and A0999 is unlisted ambulance service. 
 
We find that CPT code A0433 and A0999 is not supported in the medical record. Medicare rules says that in 
the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance 
arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched or at the fixed 
wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Neither mileage nor a rural 
adjustment would be paid. The blended rate amount will otherwise apply. Providers report the A0428 (BLS) 
HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) in 
?HCPCS/Rates? instead of the origin and destination modifier. You can find this information in the Claims 
Processing Manual, section 30.2(D). Based on this information, we decided that Medicare rules for coverage of 
the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ALS 2 
ambulance service (A0433B) and unlisted ambulance service (A0999B) provided January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the IRF care so you can be back on your 
feet as soon as possible. The Plan denied your request. The Plan says the documentation does not support that 
you require such an intense level of physician oversight for your specialized therapeutic skills or for your 
medical needs. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 12, 2018 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior 
authorization 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 has network providers 
available who can 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 OON services. Therefore, we decided 
that the Plan does not have to pay for the medical services provided on September 12, 2018 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided April 10, 2020. 
 
You asked the Plan to pay for the back brace. You say that the brace was medically necessary. The Plan denied 
your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order, medical records, and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The provided records do not describe a need for a back brace. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for a back brace (L0650) provided April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on October 14, 2019. 
 
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 rendered 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 subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out of area specialist office visit provided on March 3, 
2020. 
 
You asked the Plan to pay for the out of area specialist office visit. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services received were 
neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that the specialist office visit was not due to an 
unforeseen illness or injury, and prior authorization was not obtained. Based on this information, we decided 
that Medicare rules for coverage of the out of area specialist office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the out of area specialist office visit provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 the semi-electric hospital bed. Our 
reviewer says that the semi-electric hospital bed is not medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that the patient's condition requires 
positioning of the body in ways not feasible in an ordinary bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat bariatric surgery 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that repeat bariatric surgery is generally not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat bariatric surgery is usually not covered, 
unless there are special clinical circumstances that demonstrate reasonableness and necessity.  
 
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 the surgery. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee continues to meet CMS criteria for bariatric surgery at this time. The enrollee 
underwent the lap band which is not a metabolic or hormonal operation. She has complications related to 
GERD and the band is not being used as a tool. She has significant obesity related co-morbid conditions that 
will improve with significant weight loss. The gastric bypass has been shown to be far superior both in 
effective weight loss and durability as compared to the lap band. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve repeat bariatric surgery  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) 
provided January 22, 2020. 
 
You asked the Plan to pay for the PET scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do 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. 
 
We find that CPT code 78815 is not supported in the medical record. Specifically the claim did not include a 
valid diagnosis code for the service b. Based on this information, we decided that Medicare rules for coverage 
of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron 
Emission Tomography (PET) scan (78815) provided January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Melatonin, Fluticasone-Vilanterol, and Losartan provided 
on December 27, 2019 and December 28, 2019. 
 
You asked the Plan to pay for the Melatonin, Fluticasone-Vilanterol, and Losartan. You say that you are on a 
fixed income, and would like these services paid for. The Plan denied your request. The Plan says these drugs 
are self-administered medications, and are not covered under Part B. 
 
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 pay for the Melatonin, Fluticasone-
Vilanterol, and Losartan provided on December 27, 2019 and December 28, 2019.  
 
Benefits for the Melatonin, Fluticasone-Vilanterol, and Losartan 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral prosthetics to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the prosthetics. You say that you want to continue to receive services from 
the out-of-network provider. The Plan denied your request. The Plan says the prosthetics can only be approved 
if received from 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 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 
the bilateral prosthetics to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you were not aware of the requirement of 
obtaining a prior authorization. The Plan denied your request. The Plan says services were not authorized by 
network providers. 
 
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 lab 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 lab services provided on April 9, 2020 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4223) provided November 21, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the service is not covered. 
 
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 A4223 is not supported in the medical record. Specifically, per the 2019 National 
Physician Fee Schedule, CPT code A4223 has a status code of "X" and is not covered. Based on this 
information, we decided that Medicare rules for coverage of the infusion supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for infusion supplies (A4223) provided November 21, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the medical services provided on April 10, 
2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you are paying a charge as 
if you went to the hospital for a reading. The Plan denied your request. The Plan says the cost shares were 
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). 
 
The file shows that you received a physicians review, and technical support for pace maker services. The 
services you asked the Plan to waive the cost shares for falls within the outpatient diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided 
was received on April 10, 2020. Therefore, we decided that the Plan does not have to waive the cost shares for 
the medical services provided on April 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services because you need physical 
therapy and occupational therapy daily to help you build up your strength. The Plan denied your request. The 
Plan says the documentation does not support that you meet the Medicare criteria for an IRF. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our 
physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.