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

We decided that the Plan does not have to pay for the ambulance services provided on June 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 June 3, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 23, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or the facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan rendered on August 6, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the copayment was 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 $135 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.  
 
Review of the file shows that you received a duplex scan on August 6, 2020. You have been asked to pay a 
$135 copayment for these services. These services fall within the Medicare-covered radiological diagnostic 
service, not including x-rays 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 duplex 
scan rendered on August 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need a lift to assist 
to dialysis The Plan denied your request. The Plan says you exhausted your benefit. Medicare does not cover 
transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers a maximum 
of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on 
this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. The 25th trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device and appliance provided.

You asked the Plan to pay for intermittent limb compression device (E0651) and appliance (E0667). You say that the Plan should pay this claim.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare without record of an adequate trial of conservative care.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file does not show that the enrollee had four weeks of conservative therapy with failed response.Therefore, we decided that the Plan does not have to pay for intermittent limb compression device and appliance provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 14, 2019, by an OON provider.You asked the Plan to pay fornursing facility care. You say that the Plan should consider the claim for reimbursement.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on May 14, 2019, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 5, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physicians 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 physician's services provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision services coded 15937 provided on November 
26, 2019. 
 
You asked the Plan to pay for the excision services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services 
 
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 15937 is excision, sacral pressure ulcer, in preparation for 
muscle or myocutaneous flap or skin graft closure; with ostectomy. 
 
We find that CPT code 15937 is not supported in the medical record. Specifically, the medical records indicate 
that excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin 
graft closure was performed. There is a more appropriate Current Procedural Terminology (CPT) code that 
should be used to bill for the service provided. Based on this information, we decided that Medicare rules for 
coverage of the excision services have not been met. Therefore, we decided that the Plan does not have to pay 
for the excision services coded 15937 provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit on August 17, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $35 
copayment for a specialist visit.  
 
You had a specialist visit on August 17, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the $35 copayment.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 visit on August 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided  on 
May 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this service was a medical necessity. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you 
have a history with this provider. The Plan denied your request. The Plan says you must use network providers 
for your medical care and 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 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 medical services 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 laboratory services provided on June 25, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that none of the Plan's in-network laboratories 
can provide the diagnostic data you received. The Plan denied your request. The Plan says you must receive 
care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out 
of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan.  
 
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 June 25, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 11, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on 
August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
September 4, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided do not meet criteria for 
coverage under the member?s contractual policy. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and the Plan?s rules. Based on this information, we decided that the Plan?s rules for 
coverage of the acupuncture services have not been met.  
 
 
Specifically, the acupuncture was not provided by a physician licensed to perform the service. This means that 
the acupuncture services are not eligible for coverage by the Plan. Additionally, these services were not 
provided for treatment of chronic lower back pain and are therefore, also not eligible for coverage by Medicare. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) 
provided on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80197, 82550, 83880, 85025 
provided on May 28, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80197, 82550, 83880, 85025 are not supported in the medical record. Specifically, the 
payment for these laboratory services is included in the payment to the facility and are ineligible for separate 
payment to a physician. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 80197, 82550, 83880, 85025 provided on May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds and the testing of the 
autonomic nervous system function provided on June 25, 2020. 
 
You asked the Plan to waive the copayments for ultrasounds and the testing of the autonomic nervous system 
function. You say that you disagree with the charges because you only paid $30 in the past. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $160 
copayment for each radiological diagnostic service and a $30 copayment for non-radiological diagnostic 
services.  
 
You received an ultrasound on June 25, 2020. Therefore, you are responsible to pay the $160 copayment.  
 
You received an ultrasound on June 25, 2020. Therefore, you are responsible to pay the allowed amount of 
$112.74, which is less than the $160 copayment. 
 
You received the testing of the autonomic nervous system on June 25, 2020. Therefore, you are responsible to 
pay the $30 copayment.  
 
The total amount you owe is: $302.74.  
 
You have been asked to pay the total copayment amount of $302.74 for ultrasounds and the testing of the 
autonomic nervous system function. Ultrasounds and the testing of the autonomic nervous system function fall 
within the outpatient diagnostic services and therapeutic services and supplies 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 copayments for ultrasounds and the testing of the autonomic nervous system 
function provided on June 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 25, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not aware that you 
would owe an ambulance copayment. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. 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 ambulance services 
provided on August 25, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures (D5213). 
 
You asked the Plan to pre-approve the partial dentures. You say that you would like reconsideration because 
your current dentures do not fit correctly and cause you discomfort. The Plan denied your request. The Plan 
says your request for these services exceeds the maximum count allowed per period. 
 
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 exceed 
your benefit limit. The record indicates that you received partial dentures in 2018. The Plan allows for partial 
dentures once every five plan years. Therefore, we decided that the Plan does not have to pre-approve partial 
dentures (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 21, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you didn't have any other services 
above your annual gynecological exam done that would constitute a copayment. The Plan denied your request. 
The Plan says 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 $40 
copayment per in-network specialist office visit.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. The records show that you 
asked for a full exam, which was performed, due to a family history of colon cancer. 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 office visit provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 24, 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 10061 is not supported. 
 
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 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We find that CPT code 10061 is not supported in the medical record. Specifically, there is no documentation of 
an incision and drainage of an abscess. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical 
services rendered on May 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical 
services to be provided by an out-of-network provider.