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

We decided that the Plan does not have to waive the copay for the ambulance transport provided to the enrollee 
on February 26, 2020. 
 
You asked the Plan to waive the copay for the ambulance transport. You say that you would have made 
alternate arrangements had you known about the copay. The Plan denied your request. The Plan says that the 
copay 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 $225 
copay per ambulance trip.  
 
The enrollee has been asked to pay a $225 copay for the ambulance transport. The ambulance transport falls 
within the ambulance trip benefit category. This means that the enrollee has been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the 
ambulance transport provided to the enrollee on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 9, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair (E0240) and a raised toilet seat (E0244) 
provided on May 28, 2020. 
 
You asked the Plan to pay for a shower chair and a raised toilet seat. You say that you need these items to 
protect yourself. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of these items. Therefore, we decided that the Plan does not have to pay for a shower chair 
(E0240) and a raised toilet seat (E0244) provided on May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve promethazine tablets. 
 
You asked the Plan to pre-approve promethazine tablets. You say that this medication would benefit the 
enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 promethazine tablets.  
 
Benefits for promethazine tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories (expandable controller, 
harness, electrical connection, power seat elevation system). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that you require other types of proportional input devices 
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional 
input devices (e.g., sip and puff, head array, etc.). Your strength in the upper extremities is documented 5/5 by 
the physician evaluation. The documentation is not clear why your BUE C5/C6 muscles would be 3-/5 as per 
the PT report which is inconsistent with your injury level. Furthermore, given your independence in feeding 
and grooming there is no evidence that you require the requested accessories to operate 3 or more powered 
seating actuators through the drive control, or need a separate display ((i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) or an attendant control.) 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (expandable controller, harness, electrical connection, power 
seat elevation system).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit rendered on January 2, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that the provider told you that they were 
in-network. The Plan denied your request. The Plan says the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the primary care physician 
(PCP) services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $250 yearly deductible for your covered medical services. This cost sharing is a contractual obligation 
that had not been met at the time these services were received on January 2, 2020. Therefore, we decided that 
the Plan does not have to waive the deductible for the office visit rendered on January 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that   you are not required to get prior authorization and these services should be paid at the highest possible rate. The Plan denied your request. The Plan says unauthorized, non-plan care is not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 4, 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 facility (SNF) services provided to the 
enrollee from December 29, 2019 through January 27, 2020. 
 
You asked the Plan to pay for the SNF service. The Plan denied your request. The Plan says that the enrollee 
was responding well to interventions provided at this time with no documentation of OT/speech therapy or 
wound care needs. 
 
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 SNF service. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet 
Medicare criteria for SNF services. 
 
 
 
 
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 SNF service have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from December 29, 2019 
through January 27, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided on May 13, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because 
these services have been approved and paid in the past. The Plan denied your request. The Plan says that these 
services were not rendered by a network provider, were not urgent or emergent or authorized by the Plan. 
 
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. The Plan has failed to forward sufficient information showing that there are 
accessible contracted providers available to provide the services at issue. Additionally, the Plan has not 
demonstrated that they were ensuring continuity of care for services they have approved for prior dates of 
service. Therefore, we decided that the Plan has to pay for outpatient services provided on May 13, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopic vein harvest (33508) provided on October 25, 
2019. 
 
You asked the Plan to pay for an endoscopic vein harvest. You say that this is shown in the records. The Plan 
denied your request. The Plan says this code 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 33508 is endoscopy, surgical, including video-assisted 
harvest of vein(s) for coronary artery bypass procedure (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 33508 is not supported in the medical record. Specifically, the records do not show that 
the vein harvest was performed with video assistance. Based on this information, we decided that Medicare 
rules for coverage of an endoscopic vein harvest have not been met. Therefore, we decided that the Plan does 
not have to pay for an endoscopic vein harvest (33508) provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services received from January 6, 2019 through 
March 24, 2019. 
 
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 the claim was not filed within the required one calendar year time frame. 
 
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 the services was not filed until April 13, 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 office visit services received from January 6, 2019 through March 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on January 28, 2020 to February 8, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had to be 
transferred and you say that you are being charged another copayment for an inpatient stay. The Plan denied 
your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-6. There is no charge for additional days for inpatient hospital care/in-network.  
 
You have been asked to pay a $325 copayment per day for days 1-6. There is no charge for additional days for 
an inpatient hospital stay. The total amount you are being asked to pay is $1,950 ($325 x 6 days = $1,950). 
Since an inpatient stay was provided, the correct copayment has been applied. An inpatient hospital stay falls 
within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient hospital stay provided by a participating provider on January 28, 2020 to February 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 20, 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 the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on March 16, 2020. 
 
You asked the Plan to pay for the Guardant 360 panel. 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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant 360 panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant 360 panel provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this doctor relied on the hospital to get 
authorization for this service. You say that the doctor should not be penalized for the hospital's failure to get 
authorization. The Plan denied your request. The Plan says neither the doctor who rendered the services in 
question nor the hospital were plan providers.  The plan says that unauthorized, non-plan care is not a covered 
benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 25, 
2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance and routine supplies provided on March 18, 
2020. 
 
You asked the Plan to pay for the ambulance and routine supplies. You say that the enrollee has coverage for 
transports to and from doctors appointments. The Plan denied your request. The Plan says Original Medicare 
is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance and routine supplies provided on March 18, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fitness club membership fees for July 1, 2019 to December 
31, 2019. 
 
You asked the Plan to pay for the fitness club membership fees. You say that you were delayed in submitting 
the request for reimbursement due to illness. The Plan denied your request. The Plan says the request for 
reimbursement was not submitted timely. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym benefits 
only when requests for reimbursement of qualified membership dues are submitted no later than 31 days 
following the end of plan year. 
 
The Plans rules for coverage of gym benefits have not been met because the request for reimbursement was 
submitted after 31 days following the end of the plan year. The plan contract does not provide any exemption 
to this requirement. Therefore, we decided that the Plan does not have to pay for fitness club membership fees 
for July 1, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20611) provided on August 27, 2019. 
 
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting.  
 
We asked our coder 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 arthrocentesis. Our reviewer says that CPT code 20611 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did 
not include documentation of permanent recording and reporting. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the arthrocentesis have not been met. Therefore, we decided that the Plan does 
not have to pay for arthrocentesis (20611) provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 18, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this should have been coded with CPT 81479. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 7, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 7, 
2020.