Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lodging expenses you incurred from February 15, 2018, 
to March 2, 2018. 
 
You asked the Plan to pay for the lodging expenses. The Plan denied your request. The Plan says the benefit 
limit has been paid. 
 
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 accommodations for 
lodging will be reimbursed at the lesser of: 1) billed charges, or 2) $50 per day per covered person up to a 
maximum of $100 per day per covered person consistent with IRS guidelines.  
 
Review of the file shows that you required lodging during travel for transplant services from February 15, 
2018, to March 2, 2018. The records show that the Plan has reimbursed the maximum benefit of $50 per day 
for the lodging services. 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 lodging expenses you incurred from February 
15, 2018, to March 2, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share charged for physician services and outpatient 
diagnostic services provided. 
 
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan 
denied your request. The Plan says your providers office billed for an office visit and a diagnostic service, 
which is within their right to do.  When the Medicare allowable amount is less than the outpatient hospital 
services copayment, you are only responsible for the lesser amount(s). 
 
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 cost 
share for each service provided. 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 cost share charged for physician services and 
outpatient diagnostic services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator 
provided on February 16, 2020. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you were not 
told this was durable medical equipment or that you would have 20% coinsurance. You say that you aren't sure 
why you are getting charged 20% for monitoring services. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay $585.12, which is 20% of the allowed amount for the automatic external 
defibrillator. The allowed amount is $2,925.60 (20% x $2,925.60 = $585.12). The automatic external 
defibrillator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the automatic external defibrillator provided on February 
16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on December 18, 2019.
You asked the Plan to pay for the dental services. You say that you received "bi-wing" x-rays which were necessary to continue treatment. The Plan denied your request. The Plan says 1 intraoral x-ray per calendar year is covered. The Plan also says the frequency limit 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, the frequency limit of 1 intraoral x-ray per calendar year has been exceeded. The record shows that the plan paid for the initial intraoral x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on August 24, 2020. 
 
You asked the Plan to pay for the ambulance transport from hospital to home. You say that you cannot walk 
and you are on oxygen. The Plan denied your request. The Plan says the information received did not show you 
needed assistance to get up from bed or required administration and regulation of oxygen during transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record shows you were ambulatory and you used your own 
portable oxygen concentrator. You did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport from hospital to home have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance service provided on August 24, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the second chest x-ray, professional component provided on July 8, 
2020. 
 
You asked the Plan to pay for the second chest x-ray interpretation. You say that the physician did an 
interpretation twice. The Plan denied your request. The Plan says that this is a duplicate claim. 
 
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 pay for the second chest x-ray interpretation. Our 
reviewer says that  Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. The reports show the physician did a second 
interpretation after repositioning of the endotracheal tube. Based on this information, we decided that Medicare 
rules for coverage of the second chest x-ray interpretation have been met. Therefore, we decided that the Plan 
has to pay for the second chest x-ray, professional component provided on July 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block injection (64454) provided May 8, 
2020. 
 
You asked the Plan to pay for the genicular nerve block injection. You say that please review medical records 
attached that support this service as medically necessary and not experimental. Please reprocess this CPT for 
payment. The Plan denied your request. The Plan says Genicular nerve blocks are considered investigational 
and not medically necessary for the treatment of knee pain. 
 
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 genicular nerve block injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve block injection (64454) provided May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transvenous phrenic nerve stimulation for central sleep 
apnea. 
 
You asked the Plan to pre-approve transvenous phrenic nerve stimulation for central sleep apnea.. You say that 
it is your position that the denial for this procedure is unwarranted and unsupported by the enrolle's current 
medical status and is inconsistent with currently accepted medical practice. The Plan denied your request. The 
Plan says Medicare will not provide coverage of transvenous phrenic nerve stimulation for central sleep apnea.  
 
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 transvenous phrenic nerve stimulation for central sleep apnea. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transvenous phrenic nerve stimulation for central sleep 
apnea.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk testing lab services provided to the 
enrollee on June 2, 2020 and billed under codes 81407, 81408, and 81439. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic 
lipid panel, for symptomatic enrollees with suspected or documented cardiovascular disease.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests of this type are not covered.  
This service was requested for screening purposes. Medicare does not cover this test for screening purposes. 
Therefore, we decided that the Plan does not have to pay for cardiovascular risk testing lab services provided to 
the enrollee on June 2, 2020 and billed under codes 81407, 81408, and 81439.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on October 1, 
2018. 
 
You asked the Plan to pay for evaluation visit. You say that the enrollee did not provide proper insurance 
information upon being seen at your facility. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this claim was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for evaluation visit was not filed until June 8, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for a psychiatric diagnostic evaluation provided on October 1, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lung need biopsy with an out-of-network provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the procedure can be done at a network hospital. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lung need biopsy with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9338) provided to the 
enrollee. 
 
You asked the Plan to pay for the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the 2020 National Physician Fee Schedule lists HCPCS S9338 with a status indicator of, which indicates that this service is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This 
indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (HCPCS S9338) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs to get stronger in order for her to 
have safe transfers before she returns home. 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the submitted medical records show that the 
member has stabilized medically and is ready for discharge from the hospital. The member does not require 
skilled nursing or skilled therapy services on a daily basis.  The member does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbation of chronic medical problems. Her physical function is at or near her baseline and she can 
 
 
receive services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 24, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have a referral or prior authorization and this service was not 
ordered by a Plan 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 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 lab services provided to the 
enrollee on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that this is medically necessary. 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 grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services provided on June 5, 2020. 
 
You asked the Plan to pay for the services provided. You say that all billed units are shown in the pathology 
report. The Plan denied your request. The Plan says the service was previously approved and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim are denied. 
 
We looked at the file and the rules. The documentation shows that the service at issue has been previously paid 
by the plan. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood bank physician services provided on 
June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 11, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the only documentation you 
received from the Plan over the last 12 months was the 2019 plan year materials, which tells you that the 
comprehensive oral evaluation is covered twice per year. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. The Plan also says that you did not contact the 
Plan's customer service department to confirm benefits or limitations prior to receiving this service, and the 
Annual Notice of Changes was sent to your current address. 
 
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, comprehensive oral evaluation 
(D0150) and is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on September 16, 2019, and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for transplant-related hotel lodging provided from February 24, 2020 to 
February 27, 2020. 
 
You asked the Plan to pay for hotel lodging. You say that your spouse was with you during this stay and is 
entitled to reimbursement for every night in a hotel or apartment at the rate of $50 per night. The Plan denied 
your request. The Plan says that the denial of payment for these services is correct, because the submitted 
documentation shows the number of guests as 1 for this hotel stay. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Plan provides transplant services at a more 
distant location, the Plan must provide reasonable accommodations for the enrollee and a companion while in 
the distant location for medical care. The Plan contract says that the Plan reimburses lodging at the lesser 
amount of the billed charges or $50 per day per covered person.  
 
 
 
We looked at the file, the Plans rules, and Medicare rules. The Plan has reimbursed this stay at a rate of $50 
per day for yourself but has not issued the requested reimbursement for a companion for this stay. You say that 
a companion (your spouse) accompanied you on this trip and received lodging at this hotel on these dates of 
service. The documentation submitted does not show that this hotel stay only included one person (namely, 
yourself but not a companion); therefore, the Plan?s denial of reimbursement on this basis is not supported. 
This hotel stay lasted 3 days, resulting in a reimbursement amount of $150 for your companion during this trip. 
Therefore, we decided that the Plan has to pay for transplant-related hotel lodging provided from February 24, 
2020 to February 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the 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 physician services provided to the enrollee on July 10, 2020.