Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on April 26, 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 that the diagnosis is not supported because the enrollee is male. 
 
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 states that diagnosis code N76.0 (other inflammation of vagina and 
vulva) is not appropriate because the enrollee is male; however, the file shows that the enrollee is female. The 
Plan has not provided any further documentation to support that the services cannot be paid as billed. 
Therefore, we decided that the Plan has to pay for the emergency room (ER) services rendered on April 26, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from January 27, 2020 to 
February 17, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the SNF 
services were not medically necessary. 
 
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 did not provide a copy of the applicable medical records for this case. 
Without this information we cannot determine that the Plan's coverage rules support the denial of payment in 
this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the skilled nursing services provided from January 27, 2020 to February 17, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on March 
24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that the patient could have been safely transported by another type 
of motor vehicle. 
 
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 services. Our reviewer says 
that the ambulance services were not medically reasonable and necessary for the enrollee in this case. Upon 
ambulance arrival, the patient was sitting on the sidewalk and then walked to the ambulance and entering via 
the side door and was seated on the stretcher. He had no complaints. The patient was hemodynamically stable 
with stable vital signs. Documentation did not support that other means of transport (such as stretcher van, 
wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The 
documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer found 
that the enrollee's condition did not meet Medicare criteria for ambulance services. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided to the enrollee on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the facet 
joints. 
 
You asked the Plan to pre-approve the repeat RFA. You say that the enrollee would benefit from this treatment 
as she had good results from the prior RFA six months ago. The Plan denied your request. The Plan says the 
enrollee has had two RFA procedures in the past 7 months. 
 
Please note: We were not able to confirm the Plan's rationale that more than one RFA had been provided 
within the last 12 months. As such, we did not use this rationale in our decision. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA of the facet joints is covered when a prior 
treatment produced up to 50% pain relief for six months.  
 
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 repeat RFA. Our reviewer says that 
the requested RFA is not medically necessary. Our physician reviewer found the review indicates that the 
documentation did not show that the previous RFA at the same anatomic site provided a minimum of 50% 
improvement in pain for at least six (6) months.  The review has determined that the documentation does not 
support that the requested RFA is reasonable or necessary. 
 
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 repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat radiofrequency ablation (RFA) of the facet joints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 10, 
2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. 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 
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 hospital outpatient clinic visit provided on January 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy X-ray absorptiometry (DXA), bone density 
study provided on December 11, 2019. 
 
You asked the Plan to pay for the dual-energy X-ray absorptiometry (DXA), bone density study. 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 
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 dual-energy X-ray absorptiometry (DXA), bone density study 
provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic swallowing function study (74230) provided 
on February 17, 2020. 
 
You asked the Plan to pay for the study. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says an additional code should be reported to provide a 
more complete picture of that diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the study have not been met. Specifically, diagnosis code J69.8 has a "code first" note. This means 
that another code should be reported first to identify the substance. Therefore, we decided that the Plan does 
not have to pay for a radiographic swallowing function study (74230) provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 21, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 29, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider is not a network provider with the Plan and the services were not referred 
by a network provider. The Plan states the services are not 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the services provided on January 29, 2020 by an 
out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric services (S9480) provided on November 7, 2019 
to November 12, 2019. 
 
You asked the Plan to pay for psychiatric services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this code is not valid for Medicare. 
 
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 S9480 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of psychiatric services have not been met. Therefore, 
we decided that the Plan does not have to pay for psychiatric services (S9480) provided on November 7, 2019 
to November 12, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that initial hospital care and subsequent 
hospital care codes are "per diem" services may be reported only once per day by the same physician or 
physicians of the same specialty from the same group practice. 
 
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 not the claim for services that have been approved and paid. There 
is no evidence in the record indicating that these services were previously paid. It is the burden of the Medicare 
Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your 
favor. Therefore, we decided that the Plan has to pay for inpatient hospital services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit for assessment and 
management of a patient (CPT Code G0463) provided on October 22, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this is denied because this claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
This claim is a duplicate. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for hospital outpatient 
clinic visit for assessment and management of a patient (CPT Code G0463) provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the services you received. 
 
You asked the Plan to waive the services. The Plan denied your request. The Plan says you are responsible for 
the co payment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
 Co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
co payment for each specialist office visit.  
 
Review of the file shows that you were provided specialist services. You have been asked to pay a $5 co payment for each visit. The services fall within the specialist 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 co payment for the services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99202) on 
September 6, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the copayment should be 
waived because you were referred for Mohs surgery to an office that does not perform that procedure. The Plan 
denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit (99202) on September 6, 2019.  
 
Your complaint about being provided with an inaccurate provider referral 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office services provided on May 
29, 2020. 
 
You asked the Plan to waive the copayment for specialist office services. You say that this should be covered 
in full because the doctor requested that you come in for an office visit and you have AFIB. You state you did 
not have an option to do the in-home telehealth benefit where the copay would have been waived. The Plan 
denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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).  
 
Review of the file show that you received specialist office services provided on May 29, 2020. You are asked 
to pay a $30 copayment for the services. Your EOC states that enrollees must pay a $30 copayment for 
specialty physician. 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 specialist office services 
provided on May 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 30, 2019. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on November 30, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the nerve block injection rendered on February 6, 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 that billed diagnosis M54.5 is denied. 
 
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 states that ICD-10 diagnosis code M54.5 does not meet the associated 
relationship criteria per Local Coverage Determination (LCD) L35222; however, this LCD is not valid for the 
jurisdiction in which the services were rendered. The correct Local Coverage Article (LCA) A57589 does not 
list M54.5 as a diagnosis that does not support medical necessity. The Plan has not provided any further 
documentation or Medicare rules to support that the services are not payable as billed. Therefore, we decided 
that the Plan has to pay for the nerve block injection rendered on February 6, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.