Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office services provided on 
June 23, 2020, by an in-network provider. 
 
You asked the Plan to waive the copayment for the specialist services. You say that the specialist did not do 
much for you. The Plan denied your request. The Plan says the claim was processed accordingly with your 
2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file show that you received specialist office services 
on June 23, 2020, by an in-network provider. You are asked to pay a $45 copayment for the services. Your 
EOC states that enrollees must pay a $45 copayment for each in-network Medicare-covered visit with a 
specialist. 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 office services provided on June 
23, 2020, by an in-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept service (A0432) provided on  
August 4, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the paramedic intercept service provided does 
not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services. The rules also say that Medicare 
allows ALS paramedic intercept services only when the services are furnished in a rural area. 
 
The paramedic intercept service at issue in this appeal was not furnished in a rural area. Additionally, the Plan 
has confirmed that this provider does not have a contract with the volunteer ambulance company that provided 
the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept 
service (A0432) provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
November 19, 2019. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee 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 to the enrollee on November 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 27125 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27125 is hemiarthroplasty, hip, partial (eg, femoral stem 
prosthesis, bipolar arthroplasty). 
 
We find that CPT code 27125 is not supported in the medical record. Specifically, the records show that the 
services were performed by a provider other than the billing provider. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the surgical services rendered on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 11, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compressor, segmental home model without 
calibrated gradient pressure (CPT Code E0651) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) provided on July 1, 2020. 
 
You asked the Plan to pay for the DME. You say that the DME is necessary. The Plan denied your request. The 
Plan says the DME is not covered. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. In the indications and limitations of coverage: ?Pneumatic devices are covered only for the 
treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers.? The 
physical exam documents no ulcers or lower extremity edema. As a non-covered service it is not a benefit 
when ordered by either a contracted or a non-contracted provider. Therefore, we decided that the Plan does not 
have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT Code 
E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) provided on 
July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on June 1, 2020, 
and July 9, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you thought that copayments 
would be waived due to COVID-19. 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 $40 
copayment for each specialist visit. 
 
You had specialist visits on June 1, 2020, and July 9, 2020, for a total of 2 visits. Therefore, you are responsible 
to pay a $40 copayment per each specialist visit. The total amount you owe is: $80.   
 
You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist 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 copayments for specialist visits provided on June 1, 2020, and July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says these 
services were not an emergency, urgently needed care or out-of-area dialysis, and an authorization was not 
obtained prior to the services being rendered. 
 
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 August 17, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on June 19, 2019. 
 
You asked the Plan to pay for these services. You say that these lab services should be covered by the Plan. 
The Plan denied your request. The Plan says that the claim submitted by the provider has coding errors and this 
lab service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  There is insufficient information to indicate who these tests were 
ordered by. The assumption is these services were ordered by your physician. You would have no control over 
what tests were ordered or which lab the specimen was sent to. Insufficient information has been provided to 
substantiate the Plans denial. Therefore, we decided that the Plan has to pay for lab services provided on June 
19, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under code 
81479. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says there is no clinical documentation that member has MDD suffering from refractory moderate to 
severe depression and has failed at least one neuropsychiatric medication. The providers office confirmed the 
ordering physician is an Internal Medicine provider and does not have any other specialties. It was also 
confirmed that there is no diagnosis of Depression or Major Depressive Disorder listed as a diagnosis for this 
enrollee.  
 
The Plan must follow Medicare rules. Medicare rules say that this type of testing can only be ordered by a 
specific physician specialty. In this case, the ordering physician does not meet that specialist. Medicare rules 
for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee and billed under code 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 7, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 7, 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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a perforated ulcer with sepsis and COVID 19 pneumonia. Medical conditions are stable. There are 
no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
patient does 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 this patient 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 19, 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 CPT code R0075 and Q0092 have a PC/TC indicator of three (3), for a technical 
component only code as defined in Medicare Claim Processing Manual Chapter 23. As CPT code R0075 is a 
technical component only code, it should be reported on a hospital setting. The enrollee was in a Skilled 
Nursing facility setting from July 8, 2020 through July 20, 2020. When a patient is in a Part A SNF stay, the 
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.  
 
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, this claim was submitted for a 
service that is not eligible to be separately billed. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 
19, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT, thorax; without contrast material (CPT Code 71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that there is insufficient clinical information to approve the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer 
found the patient had chest x-ray findings which showed incidental right middle lobe infiltrate similar to prior 
study and left perihilar opacity/infiltrate increased since prior study (CT thorax was requested). Due to 
worsening of x-ray findings recently it is reasonable to follow-up with CT to further evaluate. Therefore, this 
request for CT thorax will be considered medically necessary. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, thorax; without contrast material (CPT Code 71250).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested HFCWOD. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 a HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for the requested HFCWOD. Our physician reviewer found coverage criteria for 
HFCWOD are not met.  This enrollee does not have a covered diagnosis (cystic fibrosis, bronchiectasis, 
generalized neuromuscular disease).  There is inadequate evidence that HFCWOD is beneficial in the treatment 
of COVID pneumonia.  According to the clinical notes, the enrollee is improving and currently has no cough.  
HFCWOD is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 26, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
services at issue. 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 outpatient hospital services provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had 
on July 17, 2020. 
 
You asked the Plan to waive the copayment for the clinic visit. You say that this visit was for pre-op testing.  
You believe that this cost should be included in the cost of the surgery. The Plan denied your request. The Plan 
says you were charged this copayment correctly.  The Plan notes that the copayment charged for emergency 
room services on July 29, 2020 has been waived, so this decision does not address that date of service.  
 
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 
copayment for services rendered by a physician specialist in an outpatient hospital setting.  
 
You have been asked to pay a $45 copayment for the clinic visit. The clinic visit falls within the services 
rendered by a physician specialist in an outpatient hospital setting benefit category. Medicare rules allow plans 
to charge separately for preoperative visits. 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 
outpatient hospital clinic visit you had on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
October 10, 2019 to October 17, 2019. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you feel that your billed 
portion is too high. Please reconsider the charges and send you a lower adjusted bill and you will begin paying 
the lower amount. The Plan denied your request. The Plan says the claim was processed and the correct 
copayment was applied per the Evidence of Coverage. 
 
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 $300 
copay per day for days 1-5 for covered in-network hospital stays for Inpatient hospital care.  
 
You have been asked to pay $1500 for the inpatient services. The inpatient services fall within the Inpatient 
hospital 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 inpatient hospital 
services provided October 10, 2019 to October 17, 2019.