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

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 48 one-way transportation 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 (A0120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 12, 
2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan 
says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 12, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee on May 19, 2020 and billed 
under code 70450. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was not submitted with the required modifier. The Plan says that per CMS 
NCCI edits, CPT code 70450 is a column II procedure with a component inherent to the column I procedure, 
70496. However, a modifier is permitted on the code pair to differentiate between the services provided. Per 
review of records, 70450 is supported as separate and distinct from the CPT 70496 as both were performed 
during different sessions. However, per CMS an appropriate modifier is needed to represent the services as 
separate and distinct.  
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a modifier if the 
service billed with the modifier indicates a distinct procedural service. In this case the claim billed cannot be 
paid due to a modifier error. Medicare rules for coverage of this claim are not met.  Therefore, we decided that 
the Plan does not have to pay for services provided to the enrollee on May 19, 2020 and billed under code 
70450.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary, rest home visit (99335) provided on February 
27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary, rest home visit. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is 
seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. The plan says that 
non-emergent services with non-contracted providers require prior authorization before services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 domiciliary, rest home visit (99335) provided on 
February 27, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of bone provided on February 5, 2020 billed 
with code 11044. 
 
You asked the Plan to pay for the debridement. You say that this procedure is payable when done in the office 
setting. The Plan denied your request. The Plan says the criteria are not met. 
 
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 11044 is Debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. 
 
We find that CPT code 11044 is not supported in the medical record. Specifically, there is no clear 
documentation of any procedure being performed during this office visit. Based on this information, we 
decided that Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the 
Plan does not have to pay for the debridement of bone provided on February 5, 2020 billed with code 11044.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contact lens fitting (92310) provided on June 4, 2019. 
 
You asked the Plan to pay for a contact lens fitting. You say that this denial was not clear and should be 
reversed. The Plan denied your request. The Plan says you have exhausted your vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan offers a $150 allowance once every 24 months for you to use toward the purchase price of 
eyewear. 
 
We looked at the file and the Plan's rules. The record shows that your $150 vision allowance was exhausted in 
2018. Based on this information, we decided that the Plan's rules for coverage of a contact lens fitting have not 
been met. Therefore, we decided that the Plan does not have to pay for a contact lens fitting (92310) provided 
on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (CPT Code 92015) provided on March 16, 
2020 by an out-of-network provider. 
 
You asked the Plan to pay for the eye refraction. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is not in-network with your supplemental vision 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. 
 
Review of the file show that you received the eye refraction on March 16, 2020 by an out-of-network provider. 
Your EOC states that enrollees must pay a $0 copayment for routine eye exam with preferred provider. 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 eye refraction (CPT Code 92015) provided on 
March 16, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on April 15, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on April 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services provided on July 10, 2018. 
 
You asked the Plan to pay for emergency care. You say that you do not know why the Plan did not pay for this 
claim. The Plan denied your request. The Plan says the denial of payment for these services 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 emergency care was not filed until May 11, 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 emergency care services provided on July 10, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
March 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that do not penalize your doctor for 
the hospital staff's failure in taking proper steps to obtain authorization for these services. Your physician 
provided medically necessary services in good faith. The Plan denied your request. The Plan says enrollee's 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. The plan says that non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care (99309) 
provided on March 18, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from 
November 8, 2018 to January 22, 2019. 
 
You asked the Plan to pay for the HIT services. You say that these charges are the medically necessary services 
related to the enrollee's pain pump medications. The Plan denied your request. The Plan says these charges are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9328 is not supported since it has a status indicator of "I" in the Physician Fee Schedule. This 
means that this code is invalid for Medicare billing purposes. Based on this information, we decided that 
Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy (HIT) services provided from November 8, 2018 to January 22, 
2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from 
November 21, 2019 to November 27, 2019 billed with code S5501. 
 
You asked the Plan to pay for the HIT services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says these services were not billed with a valid code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S5501 has a status indicator of "I" in the Physician Fee Schedule meaning that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy (HIT) services provided from November 21, 2019 to November 27, 2019 billed with code S5501.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. 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 on March 27, 2020. 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the PET/CT scan provided on January 
17, 2020. 
 
You asked the Plan to pay for the PET scan interpretation. You say that there are no NCD/LCD diagnoses for 
this procedure so this should be covered based on medical necessity. The Plan denied your request. The Plan 
says this PET imaging claim is not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes that may be used. 
 
We looked at the file and Medicare rules. The reported diagnosis of C18.9, for colon cancer of unspecified site 
is not listed as an appropriate diagnosis code. Based on this information, we decided that Medicare rules for 
coverage of the PET scan interpretation have not been met. Therefore, we decided that the Plan does not have 
to pay for the interpretation of the PET/CT scan provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on March 15, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you didn't receive a bill 
for this for a whole year. You say that you paid $250 for the ambulance and assumed everything else was taken 
care of. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided by a participating provider on March 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 20, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on March 20, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine provided by an out-of-
network provider on March 12, 2020. 
 
You asked the Plan to waive the copayment for nuclear medicine. You say that you do not agree with these 
copayments. 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 $275 
copayment for outpatient diagnostic tests/in-network/diagnostic radiology.  
 
You have been asked to pay a $275 copayment for nuclear medicine. Nuclear medicine falls within the 
outpatient diagnostic tests/in-network/diagnostic radiology 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 nuclear medicine provided by an out-of-network provider on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of arm joint (73221) 
performed on March 26, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of arm joint. You say that you were misinformed 
about the network status of the provider. The Plan denied your request. The Plan says the correct copayment 
was 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 $275 
copayment for outpatient diagnostic services performed by a provider other than your primary care physician.  
 
In this case, the Plan has processed this claim as an in-network service due to a temporary relaxation of normal 
procedures during the COVID-19 pandemic. You have been asked to pay $253.07 for an MRI scan of arm 
joint. An MRI scan of arm joint falls within the "Outpatient diagnostic tests and therapeutic services and 
supplies" benefit category. This means that you have been asked to pay less than the full 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 MRI scan of arm joint 
(73221) performed on March 26, 2020.  
 
Your complaint about receiving erroneous or misleading information about the network status of the provider is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on October 31, 2019 billed 
with code 11042-GW. 
 
You asked the Plan to pay for the wound care services. You say that you received an order from the enrollee's 
PCP to provide urgent care and this should not require authorization. The Plan denied your request. The Plan 
says all out of network care requires prior authorization. 
 
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. It appears 
that the enrollee's hospice status was known due to the billing of modifier -GW. Services not related to the 
terminal illness should be billed to the appropriate Original Medicare contractor for payment. Therefore, we 
decided that the Plan does not have to pay for the wound care services provided on October 31, 2019 billed 
with code 11042-GW.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on January 21, 2020 to March 
10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist services. 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. 
 
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 specialist services provided on January 21, 2020 to 
March 10, 2020 by an out of network (OON) provider.