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

 
We decided that the Plan has to pay for the ALS emergency ambulance (A0427) and ground mileage (A0425) 
provided August 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this is a 911 call and you feel you treated 
the enrollee based on the call. You have attached claim and all documentation that supports this transport. The 
Plan denied your request. The Plan says that the records does not support medical necessity for ambulance 
transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found pain is a subjective complaint. Can be a 
symptom of severe acute illnesses. Feel that the ambulance service did what was reasonable in transporting this 
patient. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pay for the emergency ambulance (A0427) and ground mileage (A0425) provided August 24, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral X-
rays (D0210) provided on September 8, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral X-rays. You say that you were 
not aware of which dental procedures you had exhausted coverage for. The Plan denied your request. The Plan 
says the services exceed the frequency limitation for the benefit 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. The Plan covers the 
comprehensive oral evaluation and intraoral X-rays when the services are medically necessary and reasonable.  
 
We looked at the file, and Medicare rules. The file indicates that the Plan last covered these services in August 
2018. Therefore, you would not be eligible for coverage until August 2021. Based on this information, we 
decided that the Plan's rules for coverage of the comprehensive oral evaluation and intraoral X-rays have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) and intraoral X-rays (D0210) provided on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided by a participating 
provider on July 22, 2020, to September 29, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that you had this done during your annual 
wellness exam. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay $19.42 which is less than your copayment amount of $20 for an EKG. When 
additional services are provided during an annual wellness exam additional copayments are applied; therefore, 
the correct copayment has been applied. An EKG falls within the outpatient diagnostic tests/other outpatient 
diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an EKG provided by a 
participating provider on September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stay from July 6 to 
July 11, 2020, and the skilled nursing facility stay from July 11 to August 19, 2020. 
 
You asked the Plan to waive the copayments for the inpatient hospital stay and skilled nursing facility stay. 
You say that you wanted to be discharged from the skilled nursing facility earlier. The Plan denied your 
request. The Plan says you have paid the correct copayment amounts for the noted services. 
 
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 $210 
copayment per day for days 1-6 for inpatient hospital stays, and a $0 copayment per day for days 1-20, then a 
$164 copayment per day for days 21-100 for skilled nursing facility care.  
 
You have been asked to pay $210 copayment per day for days 1-6 for inpatient hospital stays, and a $0 
copayment per day for days 1-20, then a $164 copayment per day for days 21-100 for skilled nursing facility 
care. The inpatient hospital stay falls within the inpatient hospital care benefit category, and the skilled nursing 
facility stay falls within the skilled nursing facility (SNF) care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the inpatient hospital stay from July 6 to July 11, 2020, and the skilled nursing 
facility stay from July 11 to August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the audiological therapeutic visits. 
 
You asked the Plan to pre-approve the therapeutic visits. You say that tinnitus is a brain disorder which causes 
your ear to hear it malfunctioning. Please give your brain problem the reality of repair for the plan to help you 
succeed. The Plan denied your request. The Plan says Medicare only covers diagnostic services with an 
audiology provider. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic visits have not been met. Therefore, we decided that the Plan does not have to pre-
approve the audiological therapeutic visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0438, 99214) provided on June 
15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit provided by an OON provider. You say that the services 
were necessary. The Plan denied your request. The Plan says there are in-network providers that were able to 
provide these services. Therefore, coverage criteria has not been met. 
 
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 annual wellness visit (G0438, 99214) provided 
on June 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 the laboratory services provided on September 20, 2019, 
through December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted documentation did not contain 
sufficient detail to support the billed charges. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
place of service code (81) but the records indicate this specimen was obtained in an outpatient rehabilitation 
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
September 20, 2019, through December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from September 21, 2020, 
through September 22, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 from September 21, 
2020, through September 22, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services coded 75774 provided on March 
24, 2020. 
 
You asked the Plan to pay for the angiography 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 supported by the 
documentation. 
 
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 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). 
 
We find that CPT code 75774 is not supported in the medical record. Specifically, the description of this code 
was documented in the operate report narrative; however, this procedure is considered inclusive to code 37244. 
Based on this information, we decided that Medicare rules for coverage of the angiography services have not 
been met. Therefore, we decided that the Plan does not have to pay for the angiography services coded 75774 
provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided to 
the enrollee on August 6, 2020. 
 
You asked the Plan to pay for the CGM supplies. You say that these supplies were medically necessary. The 
Plan denied your request. The Plan says that documentation does not reflect or mention the Continuous 
Glucose Monitor. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) supplies provided to the enrollee on August 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on September 6, 
2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed must be submitted to 
the enrollee's primary insurer first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has [indicate the 
plan's method of coordination]. As the secondary insurer, the Plan cannot be held responsible for the 
emergency department visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the thoracic lumbar sacral orthosis provided to the enrollee on July 27, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that no patient should be denied care or pain management 
solution because they are required to have historical documentation on record to measure pain. The Plan denied 
your request. The Plan says that that there was no history of an office visit conducted to show the ordering 
provider could have diagnoses or treated the member for any issues/illness for which a brace was needed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the orthosis by a provider. The provider is a contract provider. The file does not 
show that the plan provided notice that the orthosis would not be covered. Under Medicare rules, this means 
the orthosis is considered approved by the plan. Therefore, we decided that the Plan has to pay for the thoracic 
lumbar sacral orthosis provided to the enrollee on July 27, 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 waive the copayment for an ophthalmological diagnostic imaging 
procedure (92134) performed on December 24, 2019. 
 
You asked the Plan to waive the copayment for an ophthalmological diagnostic imaging procedure. You say 
that you thought there would be one charge for 2 appointments. The Plan denied your request. The Plan says 
the correct copayment was 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 Medicare-covered tests.  
 
You have been asked to pay a $20 copayment for an ophthalmological diagnostic imaging procedure. An 
ophthalmological diagnostic imaging procedure 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 an 
ophthalmological diagnostic imaging procedure (92134) performed on December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture provided on July 30, 2020. 
 
You asked the Plan to pay for the complete maxillary denture. You say that your first set of dentures developed 
hairline cracks, and you would like this second set of dentures covered by the Plan. The Plan denied your 
request. The Plan says the frequency limitation for this service has been reached. 
 
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, complete dentures are limited to one 
upper complete and/or lower complete denture every five years. The record shows that you received a complete 
maxillary denture on June 11, 2019, and your complete maxillary denture benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture provided on July 
30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided by a 
participating facility on March 30, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you do not feel like you 
should owe this. 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay a $65 copayment for urgently needed services. Since an urgent care visit took 
place, the correct copayment has been applied. Urgently needed services falls within the urgently needed 
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 urgently needed services 
provided by a participating facility on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on 
September 4, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that previously this provider has 
been approved as an in-network dentist. The Plan denied your request. The Plan says benefits for this service 
have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on September 
4, 2020 which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we 
decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on September 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan with quantitative 
evaluation of coronary calcium (75571). 
 
You asked the Plan to pay for a CT scan with quantitative evaluation of coronary calcium. You say that this 
was medically necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The service at issue is not covered. Therefore, we decided that the 
Plan does not have to pay for a computed tomography (CT) scan with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2020, by an out-
of-network (OON) provider. 
 
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 provided are not a covered benefit. 
 
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 laboratory services provided on June 8, 2020, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is 
not covered. 
 
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 a 
core buildup, including any pins when required (D2950).