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

 
We decided that the Plan does not have to pay for ambulance services provided on August 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Upon ambulance arrival, the patient 
was: ?fully alert and oriented denying any pain or injuries. Family states that they can?t get him to willingly go 
to any of his doctor?s appointments.? The patient was hemodynamically stable with stable vital signs. The 
patient could have been safely transported by another type of motor vehicle, possibly a van transport vehicle. 
Medical necessity for ambulance service is established when the patient's condition is such that use of any other 
method of transportation is contraindicated. In any case in which some means of transportation other than an 
ambulance could be used without endangering the individual's health, whether or not such other transportation 
is actually available, no payment may be made for ambulance services. Payment is made according to the level 
of medically necessary services actually furnished, even if a local government requires an ambulance response 
for all calls. There is a CPT-Code modifier (-GY) for ambulance / emergency medical services response 
without transport. Therefore, we decided that the Plan does not have to pay for ambulance services provided on 
August 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy (58100) provided on June 26, 
2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you should not owe a copayment for this 
service. The Plan denied your request. The Plan says this processed 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 $150 
copayment for outpatient surgery services.  
 
You have been asked to pay a $150 copayment for a biopsy, which is an outpatient surgery service. 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 biopsy (58100) provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit, a CT scan, and an 
outpatient surgery provided by participating providers on November 1, 2019, to August 19, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit, a CT scan, and an outpatient surgery. 
You say that you should not have to pay for this because these were all based on a past surgery. 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 $50 
copayment for physician/practitioner services/specialist, a $300 copayment for outpatient diagnostic tests/CT 
scan and a $325 copayment for an outpatient surgery.  
 
You have been asked to pay a $50 copayment for a specialist office visit, a $300 copayment for a CT scan, and 
a $325 copayment for an outpatient surgery.  
 
Date of Service Type of Service Copayment Amount Being Asked To Pay 
November 1, 2019 Specialist Office Visit $50 $50 
November 3, 2019 CT Scan $300 $300 
January 8, 2020 Specialist Office Visit $50 $50 
July 24, 2020 Surgery $325 $325 
August 19, 2020 CT Scan $300 $221.83 
 
Total Amount Being Asked to Pay: $946.83 ($50+ $300 + $50 + $325 + $221.83 = $946.82) 
 
A specialist office visit falls within the physician/practitioner services/specialist benefit category, a CT scan 
falls within the outpatient diagnostic tests/CT scan benefit category, and an outpatient surgery falls within the 
outpatient surgery 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, a CT scan, and an outpatient surgery provided by participating providers on November 1, 2019, to August 
19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from June 
18, 2020, to July 6, 2020. 
 
You asked the Plan to pay for the SNF stay. You say that you would like the claim to be reprocessed and 
approved for payment. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF stay. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. 
 
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 SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) stay provided from June 18, 2020, to July 6, 2020.
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 September 24, 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 September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
21, 2020 to June 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 a non-compliant billing of a non-documented diagnosis code was identified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG.  
 
In this case, you billed the services provided [Enter the date(s) of service] with DRG 0291. 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found the review has determined 
that MS-DRG 0291 was denied as lCD-b-CM diagnosis R65.11 "Systemic inflammatory response syndrome 
(SIRS) of non-infectious origin with acute organ dysfunction" is not supported by physician's documentation. 
The review has determined that MS DRG 291 was not the appropriate billing in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 0291. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital services provided to the enrollee from June 21, 2020 to June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can safely receive the needed care in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three core buildups, including any pins when required 
(D2950 x3). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
is not listed in the benefit chart, and is not a covered benefit. 
 
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 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three 
core buildups, including any pins when required (D2950 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on September 30, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this is a financial hardship for you. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $4,998.75. The total amount you are being asked to pay is $999.75 ($4,998.75 x 20% = $999.75). 
The correct coinsurance has been applied. An 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 coinsurance for an injection provided by a 
participating provider on September 30, 2020.
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 June 25, 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 June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and endoskeletal knee-shin 
system hydraulic swing phase control (L5814) and dampening feature (L5848). 
 
You asked the Plan to pre-approve lower limb prostheses. You say that the enrollee meets the definition of a 
functional level 3 amputee and needs these prostheses. The Plan denied your request. The Plan says the denial 
of authorization for these components is correct, because the records do not show that the enrollee is at K3 
functional level. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prosthetic components L5981, L5814, and 
L5848 are covered for beneficiaries whose functional level is 3 or above. 
 
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 lower limb prostheses. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested lower limb prosthetic components. 
Our physician reviewer found the requested K3 components are not medically necessary. The documentation 
does not indicate that the enrollee is a level 3 ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prostheses have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a flex-walk system (L5981) and endoskeletal knee-shin system hydraulic swing 
phase control (L5814) and dampening feature (L5848).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services with CPT code 00731 provided on 
September 3, 2020. 
 
You asked the Plan to pay for CPT code 00731. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention 
that requires the underlying condition to be sequenced first, followed by the manifestation. In this case, I85.10 
is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on 
this information, we decided that Medicare rules for coverage of CPT code 00731 have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services with CPT code 00731 
provided on September 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 6, 2020, through August 12, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the member never 
requested a private room. The Plan denied your request. The Plan says the claim was processed accordingly 
with the member's 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 shows that the member was admitted on August 6, 2020, and discharged on August 12, 
2020. The member was asked to pay a $150 copayment per day from August 6, 2020, through August 10, 
2020, days 1-5 of their inpatient stay. There were no copayment charges from August 11, 2020, day 6 of their 
inpatient hospital care until their day of discharge August 12, 2020. Per the member's contract there is a $150 
copayment per day required for days 1-5. The copayment is for the inpatient hospital care received, not for a 
private room. This means that the enrollee has been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided 
from August 6, 2020, through August 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to adjust the cost sharing for the eye surgeries with placement of intraocular 
lenses (V2632) and aqueous shunts (L8612) provided on July 22, 2020 and July 28, 2020. 
 
You asked the Plan to adjust the cost sharing for the two eye surgeries. You say that you do not feel you should 
be charged this much for the surgeries. The Plan denied your request. The Plan says that the items you had 
placed during the surgery are considered prostheses as they replace internal organs. As such, the 20% 
coinsurance is correctly applied. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must clearly and accurately describe the 
cost sharing related to covered services. The contract with the Plan states that there is a $100 copayment for 
outpatient surgery. 
 
In this case, the Plan indicates that since items that are considered prosthetics were placed during this surgery, a 
separate 20% coinsurance is required. However, the contract does not clearly state that integral parts of a 
surgery would be assessed a separate cost sharing. Review of the contract confirms that a layperson would not 
reasonably expect to pay any additional costs for surgery aside from the $100 copayment. Therefore, we 
decided that the Plan has to adjust the cost sharing for the eye surgeries with placement of intraocular lenses 
(V2632) and aqueous shunts (L8612) provided on July 22, 2020 and July 28, 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: Imaging
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 September 4, 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 September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81408 and 81407 provided on 
May 14, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81408 and 81407 provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion spacer device implantation. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). 
You say that this procedure is the most appropriate treatment for the enrollee. The Plan denied your request. 
The Plan says the Vertiflex Superion interspinous spacer procedure is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed 
above. The Vertiflex Superion interspinous spacer procedure would not be considered the standard of care for 
the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically 
reasonable and necessary for treatment of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion spacer 
device implantation.