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 February 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics provided home infusion 
services. 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 February 4, 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 February 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and X-Ray examinations provided on April 8, 
2020. 
 
You asked the Plan to pay for office visit and X-Rays. You say that your benefit booklet says that you only 
have to pay a copayment of $20 per visit. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because these services are not covered by Medicare or the Plan when performed by 
a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for an office visit and X-Ray examinations provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for application of infrared therapy provided from April 24, 2020 to May 5, 
2020. 
 
You asked the Plan to pay for infrared therapy. You say that you are appealing with records. The Plan denied 
your request. The Plan says that the denial of payment for these services is correct. 
 
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. The Plan covers an unlimited number of acupuncture visits including services 
for diagnosis and treatment for conditions such as lower back pain. 
 
We looked at the file, Medicare rules, and the Plan's rules. The enrollee had a diagnosis that qualifies for 
treatment by an acupuncturist under the Plan's acupuncture benefit. The Plan's benefits cover services to treat 
the enrollee's condition and do not exclude the use of infrared therapy. Although these services are not covered 
by Medicare under the conditions, the services do meet the Plan's criteria for coverage under the Plan's 
supplemental acupuncture benefits. Therefore, we decided that the Plan has to pay for application of infrared 
therapy provided from April 24, 2020 to May 5, 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: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee from August 4, 2019 to 
August 5, 2019. 
 
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 that the records indicate that the appealing provider did not perform this service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 supported by the medical records. Our physician reviewer found the enrollee 
was evaluated in the ED. Laboratory tests and x-rays were ordered and the results were noted in the 
documentation. This is sufficient evidence to support that the billed services were provided. It is unclear if the 
health plan is trying to argue that there is not a specific procedure note for the labs, or that the service facility is 
not the billing facility. Providers do not write procedure notes for labs. The providing facility appears to be one 
of several facilities within the billing provider's health system. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee from August 4, 2019 to August 5, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on March 8, 2019 
to March 15, 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 procedure code 95816 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 95816 is electroencephalogram (EEG); including 
recording awake and drowsy. 
 
We find that CPT code 95816 is not supported in the medical record. Specifically, the documentation does not 
indicate that the EEG with recording, awake and drowsy, was performed for the billed dates of service. 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 electroencephalogram (EEG) rendered on 
March 8, 2019 to March 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 14, 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 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 April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on May 5, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the provider is listed on the Plan's website. The 
Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of 
radiographic images (D0210) provided on May 5, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 29, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that there was no other dentist open because of 
Covid-19. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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. 
 
Review of the file show that you received the dental services provided on May 29, 2020 by an out-of-network 
provider. Your EOC states that services are only covered when received by a participating provider. The 
requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on May 29, 2020 by 
an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient post-stabilization care provided to the enrollee from 
December 29, 2019 to December 31, 2019. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says subsequent care was post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 medically reasonable or necessary. Our physician reviewer found the 
review indicates that after 3:57 pm on 12/29/19 the enrollee was stable and appropriate for transfer to a Plan 
facility. There were no new vital signs since triage. He was alert and oriented X4 and ambulatory with a cane. 
The post-stabilization care after 3:57 pm on 12/29/19 to 11:58 pm on 12/31/19 was not needed on an emergent 
basis. The review has determined that the treating physician did not document (in the physician notes, on a 
form, or in an order) that the enrollee was not stable for transfer on any dates of service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient post-stabilization care provided to the enrollee from December 29, 2019 to December 
31, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
January 20, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was a preventative 
visit and not a diagnostic one. The Plan denied your request. The Plan says the copayment you are being 
charged is correct. 
 
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 $95 
copayment for each covered X-ray in the outpatient department of a network hospital or facility.  
 
You have been asked to pay a $95 copayment for a diagnostic mammogram. A diagnostic mammogram falls 
within the outpatient diagnostic tests 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 copayment for a diagnostic mammogram provided on January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Paramedic services (A0432) provided May 28, 2020. 
 
You asked the Plan to pay for the Paramedic services. You say that the service should be covered. The Plan 
denied your request. The Plan says only the cost of ambulance transportation is covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS) ambulance company. In 
addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the Paramedic service does not have a contract with the volunteer ambulance 
company that provided the transport services. Therefore, we decided that the Plan does not have to pay for 
Paramedic services (A0432) provided May 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided on January 27, 2020 through March 9, 
2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services you received were an emergency due to your age. The Plan denied your request. The Plan says that the 
receipts sent are not itemized or properly coded. 
 
The Plan must follow Medicare rules. Medicare 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 at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have been met. Specifically, the record includes sufficient information to 
determine whether payment is due and the amount of payment. Therefore, we decided that the Plan has to pay 
for outpatient services provided on January 27, 2020 through March 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 pre-approve laboratory testing provided on November 19, 2019. 
 
You asked the Plan to pre-approve lab testing. You say that you provided service in good faith and should be 
reimbursed. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the documentation submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the Place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting. Therefore, the Place of Service (POS) code 81 - indicating an independent 
laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 
laboratory testing provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 29, 
2019. 
 
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 this was ordered via telemedicine. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory services provided 
to the enrollee on November 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract removal (66984) provided on January 30, 2020. 
 
You asked the Plan to pay for cataract removal. You say that this code is supported in the records. The Plan 
denied your request. The Plan says the records do not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 66984 is not supported in the medical record. Specifically, this code was billed for a 
date of service of January 30, 2020. The operative report is dated January 31, 2020. The documentation does 
not support that the billed procedure took place on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of cataract removal have not been met. Therefore, we decided that the 
Plan does not have to pay for cataract removal (66984) provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
(E2300) is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0998) provided April 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not want to be transported so you 
should not be billed for the service. The Plan denied your request. The Plan says the plan only covers 
ambulance services when the ambulance provide transportation. 
 
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 April 6, 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 ambulance services (A0998) provided April 6, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ice packs. 
 
You asked the Plan to pre-approve the ice packs. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the guideline states that equipment which is normally used for a 
non-medical purpose may not be considered ?medical? equipment to be covered. The Plan states this is true 
even if the item may have medical use. The Plan states that items that help with comfort or convenience or 
first-aid (such as ice packs or stretch bandages) are considered non-medical. 
 
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 ice packs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 3, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you would like reconsideration because 
you had to go to multiple dentists and paid partially out-of-pocket. The Plan denied your request. The Plan says 
dental CPT code D0140 is not listed as a covered service in the EOC. 
 
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 pay for a limited 
oral evaluation (D0140) provided on February 3, 2020.