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

 
We decided that the Plan does not have to waive the copayments for office visits you had with physician, an 
out-of-network emergency medicine specialist, on February 7, 2020 and February 12, 2020. 
 
You asked the Plan to waive the copayments for the out-of-network office visits.. You say that you called the 
plan and they gave you this doctor as your PCP. The Plan denied your request. The Plan says your phone 
records do not reflect that you were given this doctor as your PCP.  The phone records show that on January 3, 
2020, you called and were assigned physician as your PCP and you were also given a list of other 
physicians and locations (none of which is the doctor who performed the services in question in this appeal.) 
 
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 $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for the out-of-network office visits.. The doctor that provided 
these services is an out-of-network emergency medicine specialist, not your PCP.  There is no evidence in the 
records that you were assigned this doctor as your PCP. 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. 
 
Please note that this decision is limited to the dates of service of February 7, 2020, and February 12, 2020.  
Your Plan is handling date of service March 1, 2020 in a separate case. Therefore, we decided that the Plan 
does not have to waive the copayments for office visits you had with physician, an out-of-network emergency 
medicine specialist, on February 7, 2020 and February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that going to another doctor will delay treatment. 
The Plan denied your request. The Plan says treatment of your condition is available in 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8mg tablet. 
 
You asked the Plan to pre-approve Ondansetron 8mg tablet. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Ondansetron 8mg tablet.  
 
Benefits for Ondansetron 8mg tablet 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 pay for the monthly supply allowance for a continuous glucose 
monitor (CGM) billed for date of service March 24, 2020. 
 
You asked the Plan to pay for the monthly CGM supply allowance. You say that the documentation submitted 
supports that this claim should be paid. The Plan denied your request. The Plan says there is no valid proof of 
delivery as the items delivered are not itemized. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. There is a document which shows that a delivery was 
made on February 22, 2020; however, it does not indicate what was included in that delivery. In order to justify 
billing this monthly allowance, there must be evidence that a several month supply of CGM sensors was 
provided. Therefore, we decided that the Plan does not have to pay for the monthly supply allowance for a 
continuous glucose monitor (CGM) billed for date of service March 24, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the BRCA genetic testing rendered on March 11, 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 that the service was billed incorrectly. 
 
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 states that the service was billed incorrectly; however, there is no 
further explanation of documentation as to how the service was not billed correctly. The Plan has not provided 
any Medicare rules to support that the claim is not payable as billed. Therefore, we decided that the Plan has to 
pay for the BRCA genetic testing rendered on March 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a real time cardiac monitor (93229). 
 
You asked the Plan to pre-approve a real time cardiac monitor. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a real time cardiac monitor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found continuous real-time monitoring by telemetry services is not medically 
necessary in this case since off-line analysis of a patient activated device, auto-triggered device or extended 
continuous Holter monitor should be sufficient to identify dysrhythmias without jeopardizing patient safety. 
Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile 
telemetry services is not medically necessary in this case and has not been shown to improve health outcome 
compared to standard monitoring techniques. Mobile outpatient cardiac telemetry in this setting is more for the 
convenience of the patient/provider than it is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a real time cardiac monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a real time cardiac monitor (93229).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services codded as 97810, 97811, 97814, 
97813 and 99203 provided February 3, 2020 to February 26, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that the coverage only paid for one visit and 
you believe there were 5 total visits. The Plan denied your request. The Plan says acupuncture is not covered 
under the plan benefits. The plan paid for code 99203 in error, however the plan will not require 
reimbursement. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. 

Therefore, we decided that the Plan does not have to pay for the acupuncture services codded as 97810, 97811, 
97814, 97813 and 99203 provided February 3, 2020 to February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on April 14, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you would like reconsideration because the 
supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did 
not include an itemized billing/shipping invoice to indicate the specific supplies of a proof of delivery for the 
billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the billed supplies. Additionally, the 
documentation submitted does not include a delivery ticket for the billed date of service. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on April 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 April 13, 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 provided by you on April 
13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for chronic care management services (99487 and 99489). You say that you would 
like reconsideration because the services were medically necessary. The Plan denied your request. The Plan 
says authorization was not obtained by the provider or facility. 
 
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 June 30, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest, single view  (71045) 
provided March 17, 2020. 
 
You asked the Plan to pay for the radiology services. You say that this enrollee had multiple exams on this date 
of service. You have provided the attached reports to support the level of service. Please reconsider for 
processing. The Plan denied your request. The Plan says this is a duplicate service as this same service for the 
same date of service was already processed with another provider in the same group and same primary 
specialty. 
 
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 billing of code 71045 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
decided that the Plan does not have to pay for the radiologic examination, chest, single view  (71045) provided 
March 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan and 
intravenous (IV) infusion therapy rendered on March 18, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing 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 20% of 
the cost for Medicare-covered advanced imaging services and 20% of the cost for Medicare Part B 
chemotherapy drugs and other Part B drugs. 
 
Review of the file shows that you received a CT scan of the abdomen/pelvis on March 18, 2020. You have 
been asked to pay 20% of the cost for these services. These services fall within the Medicare-covered advanced 
imaging services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan.  
 
The file shows that you received IV infusion services on March 18, 2020. You have been asked to pay 20% of 
the cost for these services. These services fall within the Medicare Part B chemotherapy drugs and other Part B 
drugs 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 cost sharing for the computed tomography (CT) scan and 
intravenous (IV) infusion therapy rendered on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an arch support foot insert (L3010) provided on May 7, 
2020. 
 
You asked the Plan to pay for an arch support foot insert. You say that you need this to stay healthy. The Plan 
denied your request. The Plan says this is not covered for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for an arch support foot insert (L3010) 
provided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set coded S1015 and the infection 
control supplies coded S8301 provided on March 26, 2020. 
 
You asked the Plan to pay for the IV tubing extension set and the infection control supplies. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these services are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the IV tubing extension set and the infection control supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set coded 
S1015 and the infection control supplies coded S8301 provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care (99233) provided on December 16, 2019. 
 
You asked the Plan to pay for hospital care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee's previous plan is responsible for coverage of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the hospital care (99233) provided on 
December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2020 by an out 
of network (OON) provider. 
 
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 services were rendered by an out-of-network provider without 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 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 laboratory services provided on May 12, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
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 services were rendered by an out-of-network provider without 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 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 11, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel 
to home or nursing home services coded R0700 provided on April 24, 2020. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing 
home services. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the services billed are not payable. 
 
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 R0700 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
We find that CPT code R0700 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 3. This means this code is a technical component only code. 
Modifiers 26 and TC cannot be used with these codes. Based on this information, we decided that Medicare 
rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home 
services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of 
portable x-ray equipment and personnel to home or nursing home services coded R0700 provided on April 24, 
2020.