Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment provided from December 16, 2019 to 
December 26, 2019. 
 
You asked the Plan to pay for the radiation treatment. 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 radiation treatment provided from December 16, 2019 to 
December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 14, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that the patient's insurance had 
changed when they presented to the office. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
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 had network providers available 
who could have provided 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 office visit provided on August 14, 2019 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 16, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the genetic testing services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the ordering provider is a network provider with the Plan. 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 genetic testing services 
provided on January 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telemedicine specialist services provided 
by a participating provider on April 21, 2020. 
 
You asked the Plan to waive the copayment for telemedicine specialist services. You say that you were home 
when they called and you did not go in. You say that you only had a phone call. 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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for telemedicine specialist services. Telemedicine specialist 
services fall within the physician/practitioner services/specialist 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 telemedicine specialist services provided by a participating provider on April 21, 
2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a home ventilator (E0466) provided on July 10, 2019 through 
September 10, 2019. 
 
You asked the Plan to pay for the home ventilator. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted did not 
include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. 
 
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 record indicates that the Plan was provided with medical records to review. 
The Plan has not forwarded medical records, a physician order, proof of delivery or proof of their requests for 
documentation. We do not find the Plan denial to be substantiated and we must find in your favor. Therefore, 
we decided that the Plan has to pay for a home ventilator (E0466) provided on July 10, 2019 through 
September 10, 2019.
Appeal type: Outpatient Mental Health
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 from January 13, 2020, to March 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 
from January 13, 2020, to March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on July 15, 2019. 
 
You asked the Plan to pay for the nurse practitioner 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 
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 nurse practitioner services provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
March 9, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford the 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on March 9, 2020. The allowed amount is $8,566.20 and 20% of that is 
$1,713.24.  
 
You have been asked to pay the total coinsurance amount of $1,713.24 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription 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 coinsurance for a Medicare Part B drug provided on March 9, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on March 10, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that this is 
not a covered origin and destination. 
 
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 rules also say that Medicare pays for ambulance transport from any point of origin to the nearest 
hospital or skilled nursing facility (SNF) capable of furnishing appropriate care for a patient?s illness or injury. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records show that the enrollee was transported via ambulance from a 
doctor?s office to a skilled nursing facility. This type of ambulance transport covered by Medicare. The Plan 
has not submitted documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for 
the ambulance services provided on March 10, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on August 7, 2019. 
 
You asked the Plan to pay for the abdominal ultrasound with the place of service code 22 (outpatient). You say 
that the point of service is correct. The Plan denied your request. The Plan says the enrollee was an inpatient on 
the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
We find that POS code 22 is not billed correctly. Specifically, the enrollee was an inpatient at the time of the 
service. Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound 
have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound 
provided on August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 5, 2020. 
 
You asked the Plan to pay for the medical services. You say that the nursing home where the member resides 
requested these services, so they should be covered. The Plan denied your request. The Plan says unauthorized, 
non-plan care is not covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for medical services provided on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 to January 
15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered because the 
patient's nursing facility requested the services. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the nursing facility where the member was a patient is a network provider 
with the Plan. The Plan had network providers available who could have provided 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 January 6, 2020 to January 15, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chemodenervation of neck muscles for 
spasmodic torticollis (64616) performed on April 15, 2020. 
 
You asked the Plan to waive the copayment for a chemodenervation of neck muscles. You say that you should 
only be charged $35 for an office visit. 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 $350 
copayment for surgery services in an outpatient hospital setting.  
 
You have been asked to pay a $350 copayment for a chemodenervation of neck muscles. A chemodenervation 
of neck muscles falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" 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 a 
chemodenervation of neck muscles for spasmodic torticollis (64616) performed on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 3, 2020 to 
January 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says required Q code, FIPS, and CBS values were not billed on the claim. 
 
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 Q0300 is not billed correctly. Specifically, the required codes are not on the claim. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
January 3, 2020 to January 31, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT Scan of the brain (70450) provided on April 6, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this service 
denied as a duplicate in error. The Plan denied your request. The Plan says CPT code 70450 is a column II 
procedure to the column I procedure, 70496. 
 
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, we have confirmed that code the CT 
Scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a CT Scan of the brain (70450) provided on April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered 
 
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 had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 5, 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 medical services provided on September 30, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the debridement (11721). You say that you would like reconsideration because 
you were not given the correct insurance information. The Plan denied your request. The Plan says non-urgent 
services should be from network providers who are contracted with the Plan and listed in the Provider 
Directory. 
 
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 September 30, 
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee 
presented to the emergency department (ED) with cellulitis of the left foot. He was admitted and received 
intravenous (IV) antibiotics and wound care. He does not require services at the LTACH that are not available 
at the acute care hospital where he is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the head or brain provided on January 17, 2020. 
 
You asked the Plan to pay for the CT of the head or brain. You say that you would like this claim to be 
reconsidered. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the CT of the head or brain provided on January 17, 2020.