Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health care provided from February 
13, 2020, to February 24, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the services were 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others 
and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear 
that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. 
 
 
The enrollee was treated under an individualized treatment plan found in the record. It did appear that the 
records were supervised and evaluated by a physician. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient behavioral health care provided from February 13, 2020, to February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI by a participating provider on 
March 30, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you thought this would be covered y 
your insurance. You say that you cannot afford this 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 $250 
copayment for outpatient diagnostic tests/in-network/advanced imaging services.  
 
You have been asked to pay a $250 copayment for an MRI. An MRI falls within the outpatient diagnostic 
tests/in-network/advanced imaging 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 MRI provided by a participating provider on March 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis 
rendered on May 25, 2020. 
 
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 procedure code 74176 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74176 and 74177. Code 74176 is a column II code with a 
modifier indicator of 1 when billed with column I code 74177. Code 74176 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the abdomen/pelvis rendered on May 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic laparoscopy (49320) provided on March 11, 
2020. 
 
You asked the Plan to pay for the diagnostic laparoscopy. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this service was billed without the 
appropriate modifier. 
 
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 49320 is not supported in the record. Specifically, the record indicates that this 
procedure was discontinued. Modifier -53 is required when reporting a service that has been discontinued. 
Based on this information, we decided that Medicare rules for coverage of the diagnostic laparoscopy have not 
been met. Therefore, we decided that the Plan does not have to pay for the diagnostic laparoscopy (49320) 
provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on January 27, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says based in the Medicare billing guidelines;the sequela (7th character "S") cannot be listed as the primary diagnosis. The Plan states the issue is not medical necessity but that there are reporting errors on the claim. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim submitted has coding errors preventing payment in regard to the placement of the diagnosis codes. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mental health visit you had on May 22, 2020 with an out-of-network provider. 
 
You asked the Plan to pay more for the mental health visit.. You say that you have no issue paying your out-of-
network copayment, but you should have been reimbursed more for the services. The Plan denied your request. 
The Plan says you have been reimbursed the correct amount for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider accepts Medicare, then they cannot 
bill more than the Medicare-allowed amount for those services.  They are not permitted to balance bill for these 
services. In this case, the provider of these services participates in Original Medicare.  Therefore, they are only 
entitled to be paid the Medicare-allowed amount for these services.  The Medicare-allowed amount for the 
services you received is $89.92.  You have a $50 copayment, which you agree is appropriate.  That means that 
you are entitled to reimbursement of $39.92 ($89.92-$50 = $39.92).  This is the amount that you have been 
reimbursed by the Plan.  The Plan is not required to pay more than this amount.  Please note, however, that 
since this provider accepts Medicare, the provider cannot charge you more than the Medicare-allowed amount.  
You may go back to this provider to request a refund of any amounts paid above and beyond the Medicare-
allowed amount. 
 
We looked at the file and Medicare rules. Based on this information, we decided that that the Plan does not 
have to pay more for the mental health visit you had on May 22, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation services received on January 24, 2020. 
 
You asked the Plan to pay for the ambulance transportation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services received by the enrollee 
were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transportation services. Our 
reviewer says that the documentation does support that the ambulance services received by the enrollee were 
medically reasonable and necessary. Our physician reviewer found the enrollee has known mental illness. 
Competency is an issue. Therefore, the documentation supports that the ambulance services received by the 
enrollee were indicated. The enrollee met criteria for the services received. 
 
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 ambulance transportation services have not been met. Therefore, we decided 
that the Plan has to pay for the ambulance transportation services received on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient behavioral health services provided from March 3, 
2020 to April 27, 2020. 
 
You asked the Plan to pay for this service. You say that you were told these services would be covered. The 
Plan denied your request. The Plan says the provider is not a Medicare eligible provider. 
 
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 is not eligible to take Medicare 
payment. The rules say that a Marriage and Family Therapist is not eligible to receive Medicare payment. The 
provider in question is a Marriage and Family Therapist. Therefore, we decided that the Plan does not have to 
pay for outpatient behavioral health services provided from March 3, 2020 to April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $145.41 copayment charged for outpatient services 
provided on March 6, 2020. 
 
You asked the Plan to waive this copayment. You say that you were told by customer service that this 
copayment was incorrect. The Plan denied your request. The Plan says typically this service has a copayment 
of $295. In this case you are being charged less than the normal copayment because the Medicare allowed 
amount to charge for this is less than the normal copayment. 
 
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 $295 
copayment for outpatient hospital services.  In this case you are being charged less than the normal $295 
copayment. Our review shows this copayment is correct. 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 
$145.41 copayment charged for outpatient services provided on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Shoulders 
(73221). 
 
You asked the Plan to pre-approve the MRI's. You say that the MRI's are medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI's. Our reviewer says that the 
requested MRI imaging is not medically necessary. Our physician reviewer found there is full range of motion 
of both shoulders and all provocative testing for impingement and rotator cuff pathology are normal. In 
addition, no plain x-rays have been obtained. There is no specific clinical rationale for the requested MRI 
studies. 
 
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 MRI's have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the Shoulders (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 testing provided January 8, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says The Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for Guardant 360 testing 
provided to the enrollee on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission to a SNF. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the request 
for a SNF admission for observation and assessment does not meet the criteria for medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pre-approve the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
admission to a SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME and sales tax provided on March 25, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the DME and sales tax. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says that these services were not urgent or 
emergent, and were not 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 
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 DME and sales tax provided on March 25, 
2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the knee brace provided on January 20, 
2020, and knee x-ray provided on January 30, 2020, and February 28, 2020. 
 
You asked the Plan to waive the cost share for the knee brace and knee x-rays. You say that you have been 
double billed for the knee brace and were billed separately for the x-rays that were performed during follow up 
visits. You say that you were informed everything was included in your upfront payment for the surgery. The 
Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for durable medical equipment from an in-network provider and a $35 copayment for basic 
radiological services at an in-network specialist's office.  
 
You have been asked to a total of $172.28 for the knee brace and knee x-rays.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 20, 2020 Knee Brace $569.51 20% $113.90 
January 30, 2020 Knee X-Ray $29.19 $35 $29.19 
February 28, 2020 Knee X-Ray $29.19 $35 $29.19 
TOTAL:    $172.28 
  
 
 
The knee brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. The 
knee x-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
There is no provision in the contract which indicates cost share would be waived for services performed as a 
follow-up to a surgical procedure.  
 
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 cost share for the knee brace provided on January 20, 2020, and knee x-ray 
provided on January 30, 2020, and February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 14, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 14, 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 by you on 
February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa for the enrollee.You asked the Plan to pre-approveEuflexxa. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The enrollee has not tried and failed Orthovisc and Monovisc. Based on the medical records provided there is no indication that Orthovisc and Monovisc would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on June 4, 2020.

You asked the Plan to waive the copayment for the ambulance transports. You say that more cost-efficient means of transportation could have been arranged. You say that the cost is a financial hardship. The Plan denied your request. The Plan says the copayments 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 $325 for Medicare-covered ambulance services per trip.

You have been asked to pay a total of $638.51 for the ambulance transports. The ambulance transports 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 transports provided on June 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services provided from June 5, 2020, to June 7, 2020.

You asked the Plan to waive the copayment for the ER services. You say that you were in the hospital for two nights, so you would like the charges removed. 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 $120 copayment for emergency room services. This amount is waived if you are admitted to the hospital.

You have been asked to pay a $120 copayment for the ER services. Records show that you went to the ER on June 5, 2020, and then were kept in observation for two days.  Observation is not considered an admission, so the ER copayment applies. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services provided from June 5, 2020, to June 7, 2020.