Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary to go outside of 
the house with oxygen. The Plan denied your request. The Plan says there is no medical indication for this. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an Inogen portable oxygen concentrator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 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 codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of the testing being performed via blood sample. 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 laboratory services rendered on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office services to be provided by out-of-network 
neurology specialists. 
 
You asked the Plan to pre-approve office services. You say that you have been seeing these providers since you 
were diagnosed with your conditions and feel comfortable with the care you are receiving. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct, because these providers are 
out-of-network with the Plan and you can be treated by an in-network neurology specialist.  
 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 office services. Our reviewer says that 
you do not meet the Medicare criteria for continuity of care with the requested out-of-network providers. Our 
physician reviewer found you are not currently receiving any active treatment and/or medical management of 
your condition that makes it medically necessary for you to continue care with the out-of-network specialists. 
There is nothing unique about your condition that would make it medically necessary for you to continue care 
with the out-of-network specialists. You have episodic migraines and are not on a prophylactic agent. This is a 
rather standard complaint within clinical neurology practice and can be handled by most neurologists. There 
are no unique factors associated with your migraines either. The Plan has demonstrated that they have in-
network providers who are capable of addressing/managing your condition. Your medical management and/or 
follow-up care can be safely transitioned to an in-network neurology specialist at this time. You are only 
receiving acute/abortive treatments at this time for your condition. The prescriptions for your medications can 
be otherwise taken over by an in-network provider without disruption. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve office services to be provided by out-of-network neurology specialists.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe $25 copayment charged for specialist office services provided on March 23, 2020.You asked the Plan to waivethis copayment. You say that copayments for seniors were waived until September 2020.The Plan denied your request. The Plan says copayments for these types of services weer not waived and have been applied per the Plan contract agreement.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 $25 copayment for specialist office visit services. The Plan is correct, this type of copayment has notbeen waived for any reason. 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 waivethe $25 copayment charged for specialist office services provided on March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alarm device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that the enrollee lives home alone. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alarm device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency, scheduled ambulance transportation to 
dialysis appointments. 
 
You asked the Plan to pre-approve the non-emergency ambulance transportation. You say that the enrollee has 
medical conditions which require that she be transported to dialysis via ambulance. The Plan denied your 
request. The Plan says the records do not show that ambulance transport is needed. 
 
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 pre-approve the non-emergency ambulance 
transportation. Our reviewer says that the requested ambulance transportation is not shown to be medically 
reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a 76-
year-old woman with multiple medical problems, including end-stage renal disease requiring dialysis, heart 
disease, diabetes, colon cancer, venous insufficiency, chronic back pain, bilateral sciatica, morbid obesity, and 
impaired mobility. It is noted that the enrollee requires special handling and is not wheelchair able. The 
enrollee relies on ambulance medical transport for her dialysis sessions. Medical records from an office visit on 
10/5/20 is included in the case file. 
 
The documentation in the case file does not support that another means of transport (such as stretcher van, 
wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for the enrollee in this case. The 
documentation does not support that this enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 
 
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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency, scheduled ambulance transportation to 
dialysis appointments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe telephone evaluation and management service provided on April 28, 2020 byan out of network provider.You asked the Plan to pay forthe telephone evaluation and management service (99443). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay forthe telephone evaluation and management service provided on April 28, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you do not have 
anyone to drive you to your needed appointments. The Plan denied your request. The Plan says you have 
exhausted the allowed 24 one-way trips for this year. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 24 one-
way transportation trips for the 2020 calendar year. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport you received on 
June 14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you shouldn't have to 
pay this copayment because you didn't call for the ambulance, the staff at the urgent care center did. 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance transport. This copayment applies regardless 
of who calls for the ambulance. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport 
you received on June 14, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on May 5, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the services took place before the provider?s 
Medicare Certification became effective. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in freestanding 
emergency departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the record indicates that the provider's 
temporary Medicare billing privileges became effective on May 12, 2020. This is after the billed date of 
service. Therefore, we decided that the Plan does not have to pay for outpatient services provided on May 5, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 17, 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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, there is no documentation of the testing being performed via blood sample. 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 laboratory services rendered on April 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of breast localization device provided on June 
11, 2020. 
 
You asked the Plan to pay for the placement of breast localization device (19281). You say that the Plan should 
pay this claim. The Plan denied your request. The Plan says both providers are within the same group and have 
the same primary specialty. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
placement of breast localization device (19281) has a bundled relationship with code 10035 and cannot be paid 
as billed. This code cannot be paid as a separate line item. Also, the date of service in the medical record is not 
the same as on the claim. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the placement of breast localization device provided on June 
11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair and elevating leg rests provided on May 
19, 2020. 
 
You asked the Plan to pay for the manual wheelchair and elevating leg rests. The Plan denied your request. The 
Plan says 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 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for a manual wheelchair and elevating leg rests provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on July 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available to provide these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on July 1, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (CPT 01480) provided to the enrollee on November 26, 2019.You asked the Plan to pay forthe services. You say that these codes were deniedincorrectly.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 01480 AA P3 (45 units) remains not supported.The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked atthis physician's review, the file, and Medicare rules. We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified. 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 haveto pay foranesthesia services (CPT 01480) provided to the enrollee on November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI of the brain (70554) provided on June 30, 2020. 
 
You asked the Plan to pay for the MRI. You say that you would like reconsideration because this claim was 
denied as a duplicate in error. The Plan denied your request. The Plan says CPT code 70544-26 is denied 
because it is a column II procedure to the column I procedure, 70551 billed by the same provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
MRI has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for MRI of the brain (70554) provided on June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an MRI scan of the abdomen (74183) and 
a magnetic resonance contrast agent injection (A9579) received. 
 
You asked the Plan to waive the cost-sharing for an MRI scan of the abdomen and a magnetic resonance 
contrast agent injection. You say that should not have to pay this bill as referring you to an out-of-network 
provider was a mistake on your primary doctor's part. The Plan denied your request. The Plan says the correct 
cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay a $150 copayment for an MRI scan of the abdomen. You have also been asked to 
pay $4.65, or 20% of the Plan-allowed amount of $23.25, for a magnetic resonance contrast agent injection. An 
MRI scan of the abdomen falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
benefit category. A magnetic resonance contrast agent injection falls within the "Medicare Part B Prescription 
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 cost-sharing for an MRI scan of the abdomen 
(74183) and a magnetic resonance contrast agent injection (A9579) received.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says your 
Plan does not cover hearing aids provided by a provider that is not in-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by a network hearing or hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a network 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided.