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

We decided that the Plan does not have to pay for the services you received on a cruise ship and the flights you 
received from February 2, 2020, to February 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare generally does not cover items and 
services furnished outside of the United States.  The rules also say that medically necessary services are those 
that are reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. The services you received on the cruise ship were provided outside of 
the United States. These services are not covered by Medicare or your plan. The airline tickets/flight are not 
considered medically necessary services for the diagnosis or treatment of an illness or injury. 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 services you received on a cruise ship and the flights you 
received from February 2, 2020, to February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
March 9, 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 out of network lab services provided to the enrollee on March 9, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 11, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while a portion of this claim has been paid, the documentation 
submitted did not support that the denied codes were performed with blood sampling.  Blood specimen 
collection is by venipuncture; however, the lab requisition does not state the type of specimen collected for the 
billed codes. Therefore, the claim cannot be paid as billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and related information. In this case, codes 80157, 
80177, 80201, 80162, 80159, and 80173 cannot be paid as billed due to an issue with the type of specimen 
collected. Medicare rules for coverage of these codes have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on March 11, 2020 and billed under codes 80157, 
80177, 80201, 80162, 80159, and 80173.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the morphine sulfate injections and the 
ultrasounds you had on January 17, 2020 and May 15, 2020. 
 
You asked the Plan to waive the cost sharing for the injections and the ultrasounds. You say that you should 
only be charged the $40 office visit copayment for this date. The Plan denied your request. The Plan says you 
were charged these cost sharing amounts correctly. The plan says that for the ultrasound you had on January 
17, 2020, the allowed amount for this service ($37.53) is less than your copayment obligation.  That is why you 
were charged the full amount for this service.  The Plan also says that for the ultrasound you had on May 15, 
2020, the allowed amount for this service ($54.68) is less than your copayment obligation.  That is why you 
were also charged the full amount for this 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 $160 
copayment for radiological diagnostic services, including ultrasounds, and you pay 20% coinsurance for 
Medicare Part B drugs.  
 
Medicare rules allow health plans to charge multiple cost sharing amounts for services on a single date if you 
receive multiple services on that date.  On the two dates of service in question, you had office visits with your 
doctor (for which you were appropriately charged your office visit copayment.)  However, you also received 
injections and ultrasounds on these dates.  That is why you are being charged additional cost sharing. You have 
been asked to pay up to a $160 copayment for the ultrasounds you received.  As noted above, since the allowed 
amount for the ultrasounds is less than this copayment, you are only responsible for the allowed amount for 
each.  In addition, you were appropriately charged 20% coinsurance for the morphine sulfate injections you 
 
 
received since that is a Medicare Part B drug. 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 cost sharing for the 
morphine sulfate injections and the ultrasounds you had on January 17, 2020 and May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for continued care with an out-of-network 
pain management specialist. 
 
You asked the Plan to pre-approve the referral. You say that this is needed for continuity of care. The Plan 
denied your request. The Plan says the ten office follow-up visits exceeds the limits of continuity of care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you are not 
receiving any unique medication therapy and a transfer note can be requested for an in-network provider. The 
request for OON provider coverage is not medically reasonable or 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for continued care with an out-of-network pain management specialist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's care is custodial. 
 
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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there were no skilled nursing needs. 
From 11/13/2020, through 11/16/2020, the enrollee did not require any skilled nursing or rehab services on a 
daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time 
or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled 
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. 
The enrollee received skilled care and improved, however her function had plateaued by 11/13/2020, and she 
did not require any further inpatient skilled rehab services. The enrollee has had maximum gains with the 
current weight bearing status and she could be discharged to a lower level of care for further services. As of 
11/13/2020, the enrollee required custodial 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient diagnostic services you 
received on January 24, 2020. 
 
You asked the Plan to waive the copayment. You say that you should not have to pay for the services. The Plan 
denied your request. The Plan says you are responsible for the cost share. 
 
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 $25 
copayment for Medicare-covered outpatient diagnostic procedures and tests.  
 
Review of the file shows that you were provided outpatient diagnostic services on January 24, 2020. You have 
been asked to pay a $25 copayment for the services. The services fall within the outpatient diagnostic tests 
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 outpatient diagnostic services 
you received on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 2, 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 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 out of 
network physician services provided to the enrollee on April 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit securement package. 
 
You asked the Plan to pre-approve a transit securement package. You say that this is necessary. The Plan 
denied your request. The Plan says that this is not used for a medical condition and not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit securement package.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving overall, but requires an additional short term stay in the acute care hospital (less than 
25 days) to stabilize and continue ventilator weaning, which can be safely completed at the current facility. The 
patient does not require services at the LTACH that are not already available at the current facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on June 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physical therapy provided on June 29, 2020 by an 
out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on July 23, 2019. 
 
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 claim submitted does not have a valid HHPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to 
an error with the revenue codes billed.  Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on 
July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ophthalmic diagnostic imaging provided 
on June 26, 2020. 
 
You asked the Plan to waive the coinsurance for ophthalmic diagnostic imaging. You say that you disagree 
with the additional charges. 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 15% 
coinsurance for diagnostic radiology.  
 
You received ophthalmic diagnostic imaging on June 26, 2020. The allowed amount is $223.27 and 15% of 
that is $33.49.  
 
You have been asked to pay the total coinsurance amount of $33.49 for ophthalmic diagnostic imaging. 
Ophthalmic diagnostic imaging falls within the outpatient diagnostic tests and therapeutic services and 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 ophthalmic diagnostic imaging 
provided on June 26, 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 additional routine transportation trips. You say that you require additional 
trips for medical appointments. The Plan denied your request. The Plan says that the request exceeds the 
benefit limit. 
 
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 forty-eight (48) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to cover routine transportation above benefit maximum of forty-eight (48) routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 5, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. 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 February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cefaly electrical stimulation device for migraine 
treatment. 
 
You asked the Plan to pre-approve the Cefaly device. You say that you feel that this should be covered. The 
Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is assigned codes by 
the PDAC. For Medicare claims purposes, the coding listed in the PDAC product classification list is evidence 
of the correct coding for an item.  
 
In this case, the Cefaly device has been reviewed by the PDAC and was assigned code A9270, defined as non-
covered item or service. Since the correct code for this device is non-covered item, we find that Medicare 
coverage rules have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cefaly 
electrical stimulation device for migraine treatment.