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

 
We decided that the Plan does not have to pay for the routine venipuncture (36415) provided on July 8, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for routine venipuncture. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 routine venipuncture (36415) provided on July 
8, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee. 
 
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 enrollee was in 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 radiology services provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility services. You say that the SNF services are 
medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower 
level of care. 
 
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 pre-approve skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 16, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you already paid a $120 
copayment. 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 $250 
copayment for ambulance services/ground.  
 
You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services/ground 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 
ambulance trip provided by a participating provider on May 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from May 9, 
2020, through May 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you were never seen by a 
doctor and asked to be released from the hospital. You say that you were charged for services you didn't 
receive. The Plan denied your request. The Plan says the copayment applied 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 $225 
copayment each day for days 1 to 7 for Medicare-covered hospital care and a $0 copayment for additional 
Medicare-covered days.  
 
You have been asked to pay a $225 copayment for the inpatient stay. The inpatient stay falls within the 
"Inpatient Hospital Care" benefit category. The records show that you were admitted as an inpatient for one 
day. 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 inpatient stay provided from May 9, 2020, through 
May 10, 2020.  
 
 
Your complaint about this being Medicare fraud 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (L1970, L2220) provided on 
July 15, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment. You say that you were unaware prior 
authorization was required. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider; therefore, payment has been correctly denied. 
 
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 durable medical equipment (L1970, L2220) 
provided on July 15, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 10, 2020. 
 
You asked the Plan to pay for this service. You say that the Plan should cover this service. The Plan denied 
your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is needed when I am confined to 
my bed. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 8, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says in most 
cases the care the enrollee receives from an out-of-network provider will not be covered. 
 
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 July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the criteria for 
admission to an acute inpatient rehabilitation setting have not been met. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on May 20, 2020. 
 
You asked the Plan to pay for diabetic supplies. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these supplies is correct, because 
documentation does not indicate the ordering provider discussed the need for these supplies and the 
documentation does not include an itemized proof of delivery for the specific supplies billed.  
 
The Plan must follow Medicare rules. Medicare rules say that a supplier must furnish sufficient information to 
the Plan to determine whether payment is due for a claim.  
 
We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery for 
the specific items billed on this claim. The Plan requested this information, but it was not provided. Without 
this information, you have not furnished sufficient information to justify payment of this claim as it has been 
billed. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not 
been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided on May 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ligament injection procedure you had 
on June 10, 2020. 
 
You asked the Plan to reduce the copayment for the ligament injection procedure. You say that you have had 
this procedure done multiple times in the past and have only had to pay a $45 office visit copayment. You say 
you were not told this procedure would cost more than that. The Plan denied your request. The Plan says you 
were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for surgery services in an outpatient hospital setting.  
 
You have been asked to pay a $270 copayment for the ligament injection procedure. The billing shows that 
these services were provided at a facility designated as an outpatient hospital facility. That is why the ligament 
injection procedure falls within the surgery services in an outpatient hospital setting 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 reduce the copayment for the ligament injection procedure you had on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on August 16, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you received no treatment 
from the doctor. You say that you would like this amount taken off your bill. The Plan denied your request. The 
Plan says the copayment applied 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 $35 
copayment for each specialist visit, including outpatient clinic visits. 
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
"Outpatient hospital services" benefit category. The records show that you were seen for a neurology 
consultation. 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 visit provided on August 16, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the core build up (D2950) and crown (D2740) 
provided on August 20, 2019. 
 
You asked the Plan to reimburse you for the dental services. You say that the services you received were 
medically necessary. You say that they were needed as a result of a bicycle accident. You also say that a related 
claim was appealed and overturned so this should be too. The Plan denied your request. The Plan says a 
decision could not be made in the allowed time frame. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. The record shows that the crown and 
core build up that you received are non-Medicare covered dental services. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
core build up (D2950) and crown (D2740) provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network oxygen equipment provided to the enrollee on 
February 20, 2020. 
 
You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your 
request. The Plan says this case was forwarded to Maximus because the Plans timeframe for review expired. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment requires prior authorization both in network and out of network. It does not 
appear that the enrollee had prior authorization for this equipment. Therefore, we decided that the Plan does not 
have to pay for out of network oxygen equipment provided to the enrollee on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional unit of CPT 72132 provided on October 5, 
2018. 
 
You asked the Plan to pay for CPT 72132. The Plan denied your request. The Plan says only one unit is 
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 72132 is "Computed tomography, lumbar spine; with 
contrast material". 
 
We find that an additional unit of CPT code 72132 is not supported in the medical record. Specifically, the 
records show that only one CT scan was performed on the date of service in question, which was paid by the 
Plan. Based on this information, we decided that Medicare rules for coverage of CPT 72132 have not been met. 
Therefore, we decided that the Plan does not have to pay for the additional unit of CPT 72132 provided on 
October 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on February 20, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that this should only be a $5 
copayment. 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 $20 
copayment for physician/practitioner services/out-of-network/primary care physician.  
 
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the 
physician/practitioner services/out-of-network/primary care physician 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 office visit provided by a participating provider on February 20, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram, routine ECG with at 
least 12 leads (93005) provided June 2, 2020. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that you were charged for x-ray 
and EKG by your specialists. You are a heart patient with this provider and have never paid for these services. 
The billed your for $117.06. The Plan denied your request. The Plan says the claim processed with the correct 
copayment applies. 
 
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 $25 
copayment at a specialist's office.  
 
You have been asked to pay $25 copayment for the electrocardiogram. The allowed amount billed by the 
provider was $8.37. Therefore, the copayment is $8.37 instead of the $25. The electrocardiogram falls within 
the basic radiological services 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 
electrocardiogram, routine ECG with at least 12 leads (93005) provided June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement (11044) provided April 28, 2020. 
 
You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 11044 is Debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq. cm or less. 
 
We find that CPT code 11044 is not supported in the medical record. Specifically, a detailed procedure report 
documenting the debridement was not included in the records. Based on this information, we decided that 
Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the Plan does 
not have to pay for a debridement (11044) provided April 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you don't know why they 
called the ambulance. You say that an unfair amount was billed, and you shouldn't have to pay. The Plan 
denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services. 
 
You have been asked to pay $248.28, which is less than the standard $250 copayment for the ambulance 
transport. The ambulance transport falls within the "Ambulance services" 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 the ambulance transport provided.