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

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on March 
4, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were transported by 
ambulance for COVID-19 flu symptoms while more than 100 miles away from your home.  You said that this 
should be covered under your Global Emergency benefit and there should be no copayment. The Plan denied 
your request. The Plan says the providers' claims were reprocessed and you only owe the $300 ambulance 
copayment.  The plan says that the Global Emergency Benefit doesn't apply in this instance. 
 
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 $300 
copayment per one-way transport for ambulance services.  
 
You have been asked to pay a $300 copayment per one-way transport for the ambulance 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. This ambulance service is not eligible 
for the Global Emergency and Travel Assistance benefit. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) vaccine (90715) and administration (90472) provided on March 9, 2020. 
 
You asked the Plan to pay for a Tdap vaccine and administration. You say that this should be covered. The 
Plan denied your request. The Plan says coverage of this vaccine is the responsibility of the enrollee's 
prescription drug plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and 
administration. The Plan follows the same rules.  
 
Records do not show that the enrollee has been injured or directly exposed to any illness related to a Tdap 
vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) vaccine (90715) and administration (90472) provided on March 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the therapeutic exercises (97110) provided 
February 13, 2020 to April 20, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $40 
copayment for in-network physical therapy services provided at a specialist?s office.  
 
You have been asked to pay $240 ($40 x 6 visits) for the physical therapy services provided at a specialist?s 
office. 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 the therapeutic exercises (97110) provided 
February 13, 2020 to April 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the duplex scan of extracranial arteries 
(93880) provided on March 12, 2020. 
 
You asked the Plan to adjust the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 $110 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $110 copayment for the radiological diagnostic service provided. 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 adjust the copayment for the duplex scan of extracranial arteries (93880) provided on  
March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 14, 2020 to April 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought you would 
only need to pay your emergency room copayment. 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 $250 
copayment for day 1. There is a $125 copayment per day for days 2-6. There is a $0 copayment for additional 
days for the correct copayment has been applied.  
 
You have been asked to pay a $250 copayment for day 1 for an inpatient hospital stay. The correct copayment 
has been applied to the services provided. An inpatient hospital stay falls within the correct copayment has 
been applied. 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 inpatient hospital stay 
provided by a participating provider on April 14, 2020 to April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (CPT 88342 and CPT 80500) for the enrollee. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says immunocytochemistry and flow cytometry should generally not be reported for the same or similar 
specimens. 
 
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 the denied codes is: 
 
CPT 88342: 
 
Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 
 
CPT 80500: 
 
Clinical pathology consultation; limited, without review of patient's history and medical records 
 
We asked our coding 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 80500 
and 88342 shall not be reported for consultation related to a pathology or laboratory service that includes a 
physician interpretation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (CPT 88342 and CPT 80500) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the BRCA1/BRCA2 genetic testing you 
had on March 3, 2020. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that your doctor told you that no 
copay applied to this service. The Plan denied your request. The Plan says you were charged this coinsurance 
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% 
coinsurance for genetic testing.  
 
You have been asked to pay 20% coinsurance for the genetic testing. 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. There is nothing in the medical records from this date of service 
indicating you were told that no cost sharing would apply for this service. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the BRCA1/BRCA2 genetic testing you had on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and core 
buildup (D2950) provided on February 12, 2020. 
 
You asked the Plan to pay for the 2D oral/facial photographic image (D0350) and core buildup (D2950). You 
say that you were asked to pay your part at the time of service. You say that you didn't want to receive any non 
covered services. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 2D 
oral/facial photographic image (D0350) and core buildup (D2950) provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care (99308). You say that you would like 
reconsideration because the services rendered were medically necessary. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan and the member does not have out-of-network benefits. 
 
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 August 21, 2019 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 19, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider will not be covered. If you need medical care that Medicare requires our plan to cover and the 
providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, 
or your PCP, must obtain authorization from the plan prior to seeking care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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, rest home visit on March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided May 8, 2020 to May 11, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the documentation supports that the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights, given the 
renal failure and marked hyperkalemia, and no ability to dialyze the enrollee. Inpatient criteria were met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided May 8, 2020 to May 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 sets of tripper point injections (20552) in a 1month period.

You asked the Plan to pre-approve the tripper point injections. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the plan approved for 3 treatment sessions. Medicare indicates no more than 3 trigger point injection sessions during a 3 month period are typically necessary.

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 tripper point injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication presented to support the medical necessity of additional trigger point injection sessions. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of additional trigger point injection sessions as an exception to Medicare criteria. The records do not support that the additional 3 trigger point injections are medically necessary for this enrollee at this time.


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 tripper point injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 sets of tripper point injections (20552) in a 1 month period
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 28, 2020. 
 
You asked the Plan to pay for physician's 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 
physician?s 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 physician's services provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite Test in Vitro Strips. 
 
You asked the Plan to pre-approve FreeStyle Lite Test in Vitro Strips. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says no evidence was provided documenting 
that the Plan's preferred glucose test strip/disk product cannot be used for medical reasons. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. In this 
case, after multiple attempts were made by the Plan to obtain medical records, no documentation was provided 
that shows why the Plan's preferred glucose test strip/disk product cannot be used for medical reasons. 
Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite Test in Vitro Strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional physical therapy visits for the 
enrollee. 
 
You asked the Plan to provide coverage for additional visits. You say that this treatment is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 provide coverage for additional visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy 
and the records do not indicate his current functional level needs the unique skills of a professional therapist to 
safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a 
therapist, or under the supervision of a therapist. The requested services are not  part of a maintenance program 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
Medicare coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does 
not have to provide coverage for additional physical therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the consultation. You say that your face is swollen, you are in pain, and are 
unable to eat. You also say that you were advised that your teeth need to be surgically extracted before you can 
have dentures made. The Plan denied your request. The Plan says dental services performed by an oral surgeon 
are 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 26, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) provided to the enrollee on February 26, 2020.