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

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on July 15, 2020. 
 
You asked the Plan to waive the coinsurance for a walking boot. You say that you were told that you would not 
be charged for this boot. You say that you returned the boot. 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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a walking boot. The total allowed 
amount is $170.84 ($854.20 x 20% = $170.84). The correct coinsurance has been applied to the durable 
medical equipment that was provided. A walking boot falls within the durable medical equipment 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 durable medical equipment provided by a 
participating provider on July 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept provided on June 9, 2020 and July 15, 
2020. 
 
You asked the Plan to pay for paramedic intercept services. You say that this service should be covered by the 
Plan. The Plan denied your request. The Plan says Paramedic Intercept is not a covered benefit. 
 
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 in a rural area.  
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for paramedic intercept provided on June 9, 2020 and July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there are no medical or therapy needs that would qualify you for 
intensive daily skilled therapy or daily nursing. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis and had a below 
the knee amputation. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transport provided from 
January 16, 2020 to March 27, 2020. 
 
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. 
The Plan denied your request. The Plan says there was a correction made to show you do not owe $11, 690. 
However, the remaining balance for each transport provided is $275, which is a contractual obligation. 
 
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 $275 
copayment for each ambulance transport. 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 ambulance transport 
provided from January 16, 2020 to March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula for the enrollee. 
 
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request and related records do not support the medical necessity for the special food 
requested. 
 
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 the formula. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation notes the enrollee has had unintentional weight loss of greater than 10% over the 
period of 6 months. The documentation does not support the enrollee has diagnosis support by Medicare 
guideline. Medical necessity cannot be determined. 
 
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 formula have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in his current condition at a lower level of care. The Plan denied your request. The Plan says the enrollee 
has not completed the complete acute hospital care. 
 
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 physician 
reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oxygen supplementation, surveillance laboratory studies, and therapy services. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid cap 34mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid cap 34mg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided by an opted-out physician. 
 
You asked the Plan to pay for dermatology services. You say that you paid for these services out-of-pocket and 
are requesting reimbursement. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because this provider has opted out of Medicare coverage and is not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office 
services provided by an opted-out physician.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MTHFR gene analysis (81291) provided on May 4, 2020. 
 
You asked the Plan to pay for MTHFR gene analysis. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered, 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing 
for the MTHFR gene. 
 
We looked at the file and Medicare rules. Thee test at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of MTHFR gene analysis have not been met. Therefore, we decided 
that the Plan does not have to pay for MTHFR gene analysis (81291) provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare 
denies coverage for all cardiovascular risk assessment panels except the basic lipid panel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
Although Medicare does cover certain cardiovascular disease screening tests, the billed tests are not among 
those covered. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment 
testing provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI's and an ultrasound provided on July 
28, 2020. 
 
You asked the Plan to waive the copayment for MRI's and an ultrasound. You say that you disagree with the 
charges because you were not aware that you were receiving additional tests and that you would be responsible 
for copayments. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for each radiological diagnostic service. 
 
You received two MRI?s on July 28, 2020. Therefore, you are responsible to pay a $155 copayment per each 
MRI. The total amount you owe for MRI?s is $310.  
 
You received an ultrasound on July 28, 2020. Therefore, you are responsible to pay the allowed amount of 
$153.26, which is less than the $155 copayment.  
 
The total amount you owe is: $463.26. 
 
You have been asked to pay the total copayment amount of $463.26 for MRI's and an ultrasound. MRI's and an 
ultrasound fall 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 MRI's and an ultrasound provided on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have never been charged for 
this before. 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/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $250. The total amount you are being asked to pay is $50 ($250 x 20% = $50). An injection falls 
within the Medicare Part B prescription drugs/in-network 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least twelve leads; 
interpretation and report only (93010) provided June 11, 2020. 
 
You asked the Plan to pay for the ECG. You say that you have attached the necessary medical documentation 
supporting the service and procedure performed. Please review and adjust the denied claim accordingly. The 
Plan denied your request. The Plan says payment for this service would be included in the facility PPS 
payment. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary 
covered services to the beneficiary either directly or under arrangements made with outside providers. You 
provided services to the enrollee while having pre-surgery testing. Payment for this service would have been 
included under the facility claim for surgery. Payment to you for this service is the responsibility of the facility 
or hospital. Therefore, the plan is not required to pay you separately for this claim. Based on this information, 
we decided that Medicare rules for coverage of the ECG have not been met. Therefore, we decided that the 
Plan does not have to pay for electrocardiogram, routine ECG with at least twelve leads; interpretation and 
report only (93010) provided June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) and 
post and core in addition to crown (D2952) provided on August 19, 2020. 
 
You asked the Plan to pay for the crown - porcelain fused to high noble metal and post and core in addition to 
crown. You say that you would like this claim reprocessed and approved for payment. The Plan denied your 
request. The Plan says these services are not covered under your 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 pay for the crown 
- porcelain fused to high noble metal (D2750) and post and core in addition to crown (D2952) provided on 
August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the mobile x-ray services. You say that you would like reconsideration because 
prior claims for this service have always been paid. The Plan denied your request. The Plan says utilization of 
network providers is required when possible and available. 
 
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 the medical services provided on August 12, 2020 
by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 20, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the per the Medicare database the enrollee was in hospice status from December 05, 
2018 through January 23, 2020 and March 19, 2020 through March 28, 2020.  In accordance with Medicare 
guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on 
March 20, 2020. Per the regulations above, the member?s claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. It is the provider?s responsibility to verify the member?s coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice 
 
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 
physician services provided to the enrollee on March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology provided to the enrollee on August 11, 
2020 and billed under codes 81407, 81408 and 81479. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met as cardiovascular assays are not covered by 
Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the services billed are not covered by 
Medicare for screening purposes. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for molecular pathology provided to the enrollee on August 11, 2020 
and billed under codes 81407, 81408 and 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) provided 
July 31, 2020. 
 
You asked the Plan to pay for the CT scan. You say that records attached supporting that this procedure was 
performed by your provider. Please review and reprocess claim for reimbursement according to contract. The 
Plan denied your request. The Plan says payment for this service is bundled to another service billed on the 
same day by the same physician, or a physician of the same specialty in the same group, which is considered 
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 CT 
scan has a bundled relationship with code 70496 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 computed tomography (CT) head or brain (70450) provided July 
31, 2020.