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

 
We decided that the Plan does not have to pay for ambulance transport billed to the enrollee for June 23, 2020. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your 
request. The Plan says s the claim was submitted with code A0429 and QL modifier.  However, the records 
indicate the enrollee was pronounced dead after the ambulance called. The Plan states the claim should have 
been submitted with code A0428.  
 
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 claim was submitted with an 
inappropriate code. Medicare rules for coverage of this transport have not been met. Therefore, we decided that 
the Plan does not have to pay for ambulance transport billed to the enrollee for June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee 
during surgery on July 15, 2020. 
 
You asked the Plan to pay for this device. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says this claim is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility. Payment for this 
service would have been included under the facility claim. Payment to you for this service is the responsibility 
of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device provided to the enrollee during surgery on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on April 16, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital 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. 
The Plan says that the referring provider is also out-of-network. 
 
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 outpatient hospital services provided on April 16, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basivertebral intracept procedure. 
 
You asked the Plan to pre-approve the requested services. You say that evidence clearly supports the use of the 
intracept procedure as the primary treatment for chronic low back pain. The Plan denied your request. The Plan 
says more research is needed to show safety and efficacy. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. He has tried physical therapy, chiropractic, 
massage, TENS, NSAIDs, Gabapentin, and prior spine injections. His magnetic resonance imaging shows 
multiple level degenerative changes and stenosis. The requested procedure is considered experimental/ 
investigational. Therefore, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a basivertebral intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid 
due to medically necessity. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that the assisted living facility is out-of-network. 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 physician services provided on August 12, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab services you received at an outpatient 
hospital facility on January 30, 2020, and August 12, 2020. 
 
You asked the Plan to waive the copayments for the lab services. You say that you didn't receive bills for these 
labs in the past. The Plan denied your request. The Plan says you were charged these copayments 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 $15 
copayment for lab services completed in an outpatient hospital.  
 
You have been asked to pay a $15 copayment for the lab 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 
copayments for lab services you received at an outpatient hospital facility on January 30, 2020, and August 12, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig auto injector. 
 
You asked the Plan to pre-approve Aimovig auto injector. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Aimovig auto injector.  
 
Benefits for Aimovig auto injector 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection procedure you had at an 
ambulatory surgical center. 
 
You asked the Plan to waive the copayment for the spinal injection procedure. You say that you cannot afford 
this copayment. 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 $275 
copayment for outpatient services at an ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for the spinal injection procedure. The spinal injection 
procedure falls within the outpatient services at an ambulatory surgical center 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 spinal injection procedure you had at an ambulatory surgical 
center.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of a joint of the arm (73221) 
performed. 
 
You asked the Plan to waive the copayment for an MRI scan of a joint of the arm. You say that the provider 
should have informed you of the charge for the separate date of service. 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 $200 
copayment for each type of Medicare-covered diagnostic radiology service per date of service.  
 
You have been asked to pay a $200 copayment for an MRI scan of a joint of the arm. An MRI scan of a joint of 
the arm 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 copayment for an MRI scan of a joint of the arm (73221) performed.  
 
Your complaint about not receiving adequate information from your provider about your cost-sharing 
responsibility 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on 
June 4, 2020. 
 
You asked the Plan to pay for the unspecified preventative procedure. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says although they were able to 
approve other dental services received, providers are receiving a monthly stipend for D1999 and this service is 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventative procedure (D1999) provided on June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the request is not medically necessary 
because the records received show that the enrollee's condition has improved. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. It is not expected that the enrollee would improve in a reasonable period of time as she 
does not have suicidal or homicidal ideation noted and reports a decrease in auditory hallucinations with no 
visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. 
It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as she does not have dangerousness 
to self or others and was compliant with her treatment. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary and should 
be covered by the Plan. The Plan denied your request. The Plan says the guidelines for coverage of SNF care 
have not been met because there is no noted daily skilled complex nursing or therapy 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for pain with effect. The enrollee's lungs were clear. The 
enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee 
was at a maximal assist level with functional mobility. The enrollee required varying assist with activities of 
daily living. The enrollee tolerated a mechanical soft diet and thin liquids. There are no identifiable skilled 
 
 
nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the 
severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT Code 99291) provided on August 26, 2019, and 
September 4, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 CPT code 99291 is not supported in the medical record. Current Procedural Terminology (CPT) 
code 99291 remains not supported. The documentation submitted did not support a critical care visit of 30-74 
minutes was performed on the billed date of service. The documentation does not include the time spent 
providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. 
It is noted that multiple attempts were made to contact the provider for additional information. 
 
Current Procedural Terminology (CPT) code 99291 remains not supported. The documentation submitted did 
not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not include the time spent providing this service; therefore, the billed Critical Care 
Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact 
the provider for additional information. 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 critical care, 
evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 
99291) provided on August 26, 2019, and September 4, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Vitamin D testing provided on November 15, 2019. 
 
You asked the Plan to pay for Vitamin D testing. You say that you have no control over the way the provider 
billed this claim. The Plan denied your request. The Plan says that the denial of payment for this service is 
correct, because this test is not covered by Medicare. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. The rules say that Vitamin D testing may be covered by Medicare. 
 
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 did not specify whether the ordering physician for this testing was in-
network or out-of-network with the Plan. The documentation submitted does not include prior notice that this 
testing would not be covered. This testing is not excluded from Medicare and could be covered under some 
conditions. Without this information, we cannot determine whether the lab order made constituted plan-
directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for Vitamin D testing provided on 
November 15, 2019.   
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to specific durable 
medical equipment and supplies brands. 
 
We looked at the file and Medicare rules. The requested services are Contour Next test strips. The Plan covers 
diabetic testing supplies from the preferred brand, OneTouch. The services are available from the preferred 
brand. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted to the hospital 
from the emergency room. You say that your copayment should be waived. The Plan denied your request. The 
Plan says the copayment 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 $100 
copayment for each Medicare-covered emergency room visit. 
 
You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were in outpatient observation, which still applies the ER 
copayment. 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 ER visit provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Fluorodeoxyglucose f-18 fdg, diagnostic, 
per study dose, up to 45 millicuries (A9552) provided on July 6, 2020. 
 
You asked the Plan to waive the copayment for F18 fdg. You say that you should not be responsible for the 
cost share. The Plan denied your request. The Plan says the cost share was 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 20% 
coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a 20% coinsurance for F18 fdg. This service 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 copayment 
for Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries (A9552) provided on July 6, 
2020.