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

 
We decided that the Plan does not have to waive the copayment for the ambulance services received on May 5, 
May 8, May 9, May 10, and May 18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unconscious 
and had no say in when or how you were moved. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $325 
copayment for each ambulance trip. You had 5 ambulance trip(s). The Plan charged you $1,625 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance services received on May 5, 
May 8, May 9, May 10, and May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on May 23, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that you were not admitted to the hospital but 
were released to go home. The Plan denied your request. The Plan says the ambulance service was not 
medically necessary. 
 
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 provider submitted their claim for payment with a GY modifier that indicates that the services 
provided were non-covered by Medicare.  The ambulance provider has submitted a claim that cannot be paid 
based on Medicare billing guidelines. Because the provider is out-of-network, the plan cannot over-ride the 
claim. Therefore, we decided that the Plan does not have to pay for the ambulance service provided on May 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided by a participating 
provider on February 24, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that you shouldn't have to pay for this 
because you had your annual wellness exam done on the same day. 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 $10 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a $10 copayment for an EKG. When services are provided that go beyond an 
annual wellness exam additional copayments are applied to the appropriate services; therefore, the correct 
copayment has been applied. An EKG falls within the outpatient diagnostic tests/other outpatient diagnostic 
tests 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 EKG provided by a 
participating provider on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on August 22, 2019. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services that you provided from January 2, 
2020 to February 20, 2020. 
 
You asked the Plan to pay for the psychotherapy services. 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 psychotherapy services that you provided from January 2, 2020 
to February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on May 4, 
2020. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you thought all video chat 
appointments were covered at 100%. 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 the specialist services on May 4, 2020. You are asked to pay a $35 
copayment for the specialist services. Your EOC states that enrollees must pay a $35 copayment for each 
specialist visit for Medicare-covered services. 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 
specialist services provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 27, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 27, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for CPT code G0483 provided on January 9, 2020. 
 
You asked the Plan to pay for CPT code G0483. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of 
CPT code G0483 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the documentation provided 
shows that at least 22 or more drug classes were tested from. Based on this information, we decided that 
Medicare rules for coverage of CPT code G0483 have been met. Therefore, we decided that the Plan has to pay 
for CPT code G0483 provided on January 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the laboratory services are not supported in the medical records provided. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the  pneumatic compression device (E0676) provided to the 
enrollee on January 31, 2020. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this was medically necessary for 
the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for the  pneumatic compression device (E0676) provided to the enrollee on 
January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 6, 2019. 
 
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 December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 3, 2019. 
 
You asked the Plan to pay for the laboratory 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 
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 3, 2019.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the SNF services provided from December 13, 2019 to December 31, 
2019. 
 
You asked the Plan to pay for the SNF services. You say that at the time of the services, you were not aware 
that prior authorization was required. You also say that the enrollee has coverage for skilled nursing, and you 
feel this should be covered. The Plan denied your request. The Plan says that a denied prior authorization was 
provided to the enrollee. The Plan also says that these services are not covered under any condition. 
 
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 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 SNF services provided from December 13, 2019 to December 31, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stay from February 
7, 2020 to February 19, 2020 and the skilled nursing facility (SNF) stay from February 19, 2020 to March 9, 
2020. 
 
You asked the Plan to waive the copayments for the inpatient hospital stay and the SNF stay. You say that you 
feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you received inpatient hospital care from February 7, 
2020 to February 19, 2020 and SNF care from February 19, 2020 to March 9, 2020. The Plan says that the 
correct copayments have applied per your contract with the Plan. 
 
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 $225 
copayment per day (Days 1-6 only) for each Medicare-covered in-network inpatient hospital stay, a $0 
copayment per day for day 1-20 for SNF care and a $160 copayment per day for days 21-62 for SNF care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from February 7, 2020 to February 19, 2020. You have been asked to pay a $225 copayment per 
day for days 1-6 of this stay, totaling $1350. The inpatient hospital stay falls within the Inpatient hospital 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. 
 
The file also shows that you received SNF care from February 19, 2020 to March 9, 2020. You have been 
asked to pay a $160 copayment per day for days 21-35, totaling $2400. The SNF care falls within the Skilled 
nursing facility 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 copayments for the inpatient 
hospital stay from February 7, 2020 to February 19, 2020 and the skilled nursing facility (SNF) stay from 
February 19, 2020 to March 9, 2020.  
 
Your complaint about the possibility of being discharged too soon 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 pay for the office visit rendered on February 21, 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 cannot be paid as billed. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99202 (office visit) was billed 
with diagnosis codes that indicate laterality and laterality cannot be applied to this code. Therefore, we decided 
that the Plan does not have to pay for the office visit rendered on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foam dressing (A6212) provided on October 29, 2019. 
 
You asked the Plan to pay for the foam dressing. You say that you would like reconsideration because the 
supplied wound dressings were medically necessary. The Plan denied your request. The Plan says the member 
was enrolled in hospice on the billed date of service. 
 
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 foam dressing (A6212) provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 28470) provided to the enrollee on 
January 23, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed service, modifier, and units cannot be verified. 
 
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 28470 is "Closed treatment of metatarsal fracture; 
without manipulation, each." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the ER 
report did not include detailed documentation of a closed treatment of metatarsal fracture, to verify this 
procedure had been performed. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services (CPT 28470) provided to the enrollee on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pride wheeled scooter provided on March 30, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for a wheeled scooter. You say that you need this scooter to alleviate your struggles. 
The Plan denied your request. The Plan says this was 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 items 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 Pride wheeled scooter provided on March 30, 2020 by an out 
of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services rendered on February 18, 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services rendered on February 18, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.