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

 
We decided that the Plan does not have to pay for ambulance services provided on July 2, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services in dispute were 
medically necessary. The Plan denied your request. The Plan says the non-emergency ambulance services were 
not reasonable and necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 criteria for coverage have not been met. Our physician reviewer found the medical records show the 
enrollee was able to sit in a wheelchair, stand, and transfer. The ambulance services in question were non-
emergent. The enrollee's level of functionality documented that the ambulance services were not indicated. 
 
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 not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on July 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the 12 physical therapy visits. You say that the PT visits are medically necessary. The 
Plan denied your request. The Plan says the request for 12 physical therapy visits does not meet medical necessity 
criteria. The enrollee completed the 16th visit on September 30, 2020. The physical therapy note does not indicate any 
new injuries, recent trauma or recent surgery. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 
 
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 12 physical therapy visits. Our reviewer says that skilled 
services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy 
for the enrollee's condition. The enrollee has had prior therapy for this condition and it does not appear that the patient's 
functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that 
the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The plan 
on September 30, 2020 was to discharge to an independent home exercise program. The  specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollees 
current condition or to prevent or slow further deterioration. 
 
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 12 physical therapy visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 12 physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not to waive the coinsurance for injections and copayment for diagnostic procedures 
provided by a participating provider on May 12, 2020, to May 26, 2020. 
 
You asked the Plan to waive the coinsurance for injections and copayment for diagnostic procedures. You say that you 
should only have a $200 copayment. The Plan denied your request. The Plan says the correct coinsurance and copayment 
have 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 and a $100 copayment for outpatient diagnostic tests/diagnostic 
procedures and tests/outpatient hospital.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for injections and a $100 copayment for 
diagnostic procedures. The total amount you are being asked to pay is $3,011.03. Injections falls within the Medicare Part 
B prescription drugs/in-network benefit category and diagnostic procedures falls within the outpatient diagnostic 
tests/diagnostic procedures and tests/outpatient hospital 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 injections and 
copayment for diagnostic procedures provided by a participating provider on May 12, 2020, to May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 June 15, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Neuromuscular junction testing with CPT code 95937 provided on April 13, 2020.You asked the Plan to pay forCPT code 95937. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring.Therefore, we decided that the Plan does not have to pay forthe Neuromuscular junction testing with CPT code 95937 provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits provided on January 23, 
2020, and May 18, 2020. 
 
You asked the Plan to waive the copayment for the office visits. You say that your insurance should cover 
some things. The Plan denied your request. The Plan says the copayments 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 $50 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $50 copayment for each visit.  
 
Date of Service Service Standard Copayment Plan Paid Member Liability 
January 23, 2020 Office Visit $50 $39.34 $50 
May 18, 2020 Office Visit $50 $39.34 $50 
TOTAL:    $100 
 
The office visits fall within the "Physician/Practitioner services, including doctor?s office visits" 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 office visits provided on January 23, 2020, 
and May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided. 
 
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting place of service 11. 
 
 
 Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on June 25, 2020. 
 
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says a registered 
nurse first assistant is not recognized for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on June 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on January 18, 2019.
You asked the Plan to pay for this service. You say that this in network provider was too busy and you chose to go to the other provider instead. The Plan denied your request. The Plan says the provider used is both out of network and also a free-standing emergency room that is not affiliated with a Plan hospital. This type of facility is not covered by the Plan or by Medicare.
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 Provider is also not affiliated with a Medicare contract hospital. 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 emergency room services provided on January 18, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the bone density study provided on June 11, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
benefit maximum for the time period has been reached. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The file shows that you received a bone density study on June 11, 2020. You last received this service on 
February 23, 2018. The Plan says you must pay for the services provided. Based on the Plan contract, however, 
bone mass measurements are covered every 24 months, with no cost share. Therefore, we decided that the Plan 
has to pay for the bone density study provided on June 11, 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 pay for the lab services provided on July 31, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you did not know that prior authorization was 
needed. You said that these services were rendered in good faith and should be paid. The Plan denied your 
request. The Plan says unauthorized, non-plan care is not covered. The Plan says that your organization has 
been advised multiple times that prior authorization is required in order for services to 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 provider in this case is not a network provider with the Plan. 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 lab services provided on July 31, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 18, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a provider office visit. You say that these medically necessary services were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have 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 medical services provided on June 18, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist services provided on July 9, 2020. 
 
You asked the Plan to pay for the services provided. You say that you already paid your copay. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copay for medically-necessary care in a specialist's office.  
 
You have been asked to pay a $45 copay for the specialist's office services provided. The services fall within 
the physician 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 pay for the specialist services 
provided on July 9, 2020.  
 
Your complaint that you already paid your copay is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan and/or provider. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin.
You asked the Plan to pre-approve the Oxycontin. You say that you have cancer related pain that is uncontrolled. The Plan denied your request. The Plan says the requested drug is not covered under Part B. The Plan says that they do not administer any Part D benefits under your contract.
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 Oxycontin.
Benefits for the Oxycontin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical conditions are at a baseline, including lung disease, diabetes, heart 
disease, and past stroke. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (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 oral medications, neurologic monitoring, surveillance 
laboratory studies, tube feedings, 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 24, 2020 and 
August 27, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the chiropractor was in network and the 
manipulation of the spine should be covered. The Plan denied your request. The Plan says manipulation of the 
spine is covered but the other services provided by the chiropractor are not a covered benefit. 
 
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 chiropractic services provided on August 24, 2020 and August 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 1, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you had emergency room services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on August 1, 2020. You have been asked to pay a $65 copayment for the emergency room services. 
The emergency room services fall within the Emergency 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 copayment for the emergency room services provided on August 1, 2020.