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

 
We decided that the Plan does not have to pay for a fixed-wing air ambulance transport (A0430, A0435) 
provided April 25, 2020. 
 
You asked the Plan to pay for the air ambulance transport. You say that the air ambulance services were 
medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported 
safely by ground. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our reviewer 
says that the air transport was not medically necessary. Our physician reviewer found there is no 
documentation that the enrollee's condition was such that the time needed to transport the enrollee by ground, 
or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered 
their health. 
 
 
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 air ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pay for a fixed-wing air ambulance transport (A0430, A0435) provided April 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 3, 4, and 7. 
 
You asked the Plan to pre-approve the crowns. You say that the treatment for tooth # 3 has not been completed. 
You say that tooth # 4 is missing a piece after an accident. You also say you were advised by a plan 
representative that 2 crowns are covered per year. The Plan denied your request. The Plan says porcelain 
crowns are not listed as a covered service. 
 
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 and crowns are a covered service, 
porcelain crowns, specifically, are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 3, 4, and 7.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that you are in fear for your health. The Plan denied your 
request. The Plan says a liquid biopsy in September showed no targetable mutation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab for the 
treatment of non-small lung cancer and esophageal cancer requires PD-L1 testing of at least 1%. There is no 
PD-L1 testing provided for this patient. The service is not reasonable or 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology genomic profiling 
provided to the enrollee on January 3, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a molecular pathology genomic 
profiling for esophageal cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the molecular pathology genomic profiling provided to the enrollee on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis, LT, RT (L1907x2) Addition to lower 
extremity, varus/valgus correction, plastic modification, padded/lined, LT,RT (L2275x2) provided April 11, 
2020). 
 
You asked the Plan to pay for the orthoses. You say that You are appealing this denial and believe the claim 
should be paid. You have fully complied with Medicare guidelines and have supporting documentation. The 
Plan denied your request. The Plan says the records do not support the service billed. 
 
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 a valid proof of delivery or an itemized shipping/billing invoice to indicate the 
specific supplies. The delivery ticket submitted did not include the carrier's tracking number, and the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted. 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 ankle orthosis, LT, RT (L1907x2) Addition to lower 
extremity, varus/valgus correction, plastic modification, padded/lined, LT,RT (L2275x2) provided April 11, 
2020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99204) provided on June 5, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that you just moved and needed to see a provider 
to continue your medications. The Plan denied your request. The Plan says this provider was not a network 
provider, the services were not urgent, nor were they approved in advance. 
 
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 office outpatient visit (99204) provided on 
June 5, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of pelvis (72190) provided on June 25, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the x-ray of pelvis. You say that you would assume all authorizations would have 
been received. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the x-ray of pelvis (72190) provided on June 25, 
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 chemical cauterization of granulation tissue (17250) 
provided on May 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chemical cauterization of granulation tissue. You say that the services rendered 
were medically necessary. The Plan denied your request. The Plan says no authorization was obtained, it was 
not an emergency service, and there are network providers available for the delivery of this service. 
 
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 chemical cauterization of granulation tissue 
(17250) provided on May 20, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 12, 2020, 
to March 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services 
were not medically necessary. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 12, 2020, to March 31, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on April 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this claim does not include an 
appropriate primary, first-listed or principal diagnosis for any procedure or service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes A0427 and A0425 are supported in the record. Specifically, this claim was billed with 
T50.905A as the primary diagnosis. Per the ICD-10-CM, this is an appropriate primary or first-listed diagnosis 
code. 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 ambulance services (A0427 and A0425) provided 
on April 30, 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 waive the copayment for the urgent care center visit you had on 
December 30, 2019. 
 
You asked the Plan to waive the copayment for the urgent care center visit. You say that you did not go to 
urgent care on this date because it wasn't open. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for urgent care services.  
 
You have been asked to pay a $40 copayment for the urgent care center visit. The medical records from this 
date of service clearly show that you were seen for complaints of hand swelling resulting from a cat biting you. 
You were diagnosed with cellulitis and prescribed Augmentin for this issue. 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 urgent care center visit you had on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital services 
you received from April 10, 2020 through April 19, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that if 
you had known this facility was considered an inpatient rehabilitation hospital instead of a skilled nursing 
facility, you would have chosen a different facility. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 and $0 per day for days 6-90 for inpatient rehabilitation services.  
 
You have been asked to pay a $325 copayment per day for days 1-5 for the inpatient rehabilitation hospital 
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 waive the copayment for inpatient rehabilitation hospital services you 
received from April 10, 2020 through April 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has end stage renal disease and is on 
chemo dialysis three times a week. You say that the enrollee will benefit from a rehab facility that will be able 
to provide in-house dialysis so that he can continue physical therapy. You say that the enrollee has no home 
support and that a return home would be unsafe. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for falls and respiratory failure. The enrollee's medical problems are stable and there are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office or other outpatient visit (99204) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the office or other outpatient visit. You say that you would like to continue 
care due to having previous history with the OON provider. The Plan denied your request. The Plan says they 
have approved you to see a contracted 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 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 
the office or other outpatient visit (99204) to be provided 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 home health services provided to the enrollee from April 
19, 2019 to April 25, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim has not been submitted timely or 
billed correctly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim has been billed incorrectly. The claim has been submitted with an invalid type of bill code. 
Type of bill code 327 is the appropriate type of bill code for adjusted claims. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from April 19, 2019 to April 25, 
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837, 90791) provided by 
a Licensed Professional Counselor (LPC) from May 7, 2020, to May 28, 2020. 
 
You asked the Plan to pay for outpatient mental health services. You say that you did not know this would not 
be covered. The Plan denied your request. The Plan says this provider is ineligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. Licensed Professional Counselors are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. The provider you received these services from is not eligible to enroll 
in the Medicare program. Based on this information, we decided that Medicare rules for coverage of outpatient 
mental health services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services (90837, 90791) provided by a Licensed Professional Counselor (LPC) from 
May 7, 2020, to May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says the benefit 
limit has been reached. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.