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

 
We decided that the Plan does not have to pay for the ambulance services provided on March 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the paramedics took your vitals and the 
decision was made to stay home. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 22, 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 on March 22, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 10, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you have a letter stating the 
service has been approved. You say that you should be refunded. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
limited oral evaluation (D0140) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the diagnostic testing provided on March 18, 
2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the amount billed is above what 
your plan says. The Plan denied your request. The Plan says the cost share is a contractual obligation, and 
cannot be waived. 
 
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 
copay for each Medicare-covered radiological diagnostic service.  
 
The file shows that you received 2 ultrasounds. One on the right foot, and one on the left foot. You have been 
asked to pay a $110 copay for each test. The services fall within the outpatient diagnostic tests 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 copay for the diagnostic testing provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 17, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you feel that the laboratory failed to seek the 
required approval for these services, so you should not be liable for these charges. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 17, 2019 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
January 15, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the mammogram was a 
recheck to a previous mammogram and you feel that you should not owe a copayment. 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 a $100 
copayment for diagnostic procedures and tests provided in an outpatient hospital facility.  
 
The medical records show that you had a diagnostic mammogram at an outpatient hospital facility on January 
15, 2020. Therefore, you are responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for preparation and provision of antigens for 
allergen immunotherapy (95165) on March 24, 2020. 
 
You asked the Plan to waive the copayment for preparation and provision of antigens for allergen 
immunotherapy. You say that you should not have copayments for this provider. The Plan denied your request. 
The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per visit to a specialist.  
 
You have been asked to pay a $20 copayment for preparation and provision of antigens for allergen 
immunotherapy. Preparation and provision of antigens for allergen immunotherapy falls within the 
"Physician/Practitioner services, including doctor?s office visits" 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 preparation and provision of antigens for allergen immunotherapy (95165) on 
March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGX Comprehensive Cancer panel rendered on October 
7, 2019. 
 
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 testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology procedures are covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of ovarian 
cancer. The enrollee's family history is notable for breast cancer in her mother, and leukemia in her brother. 
The documentation in the case file does not support that the results of the testing would directly impact the 
treatment or management of the enrollee in this case. It is not documented that alternative laboratory or clinical 
tests to definitively diagnose the disorder/identify the condition were unavailable or that the results were clearly 
equivocal. The documentation does not support that the CGX Comprehensive Cancer panel was medically 
reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the CGX Comprehensive Cancer panel rendered on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Reblozyl. Our reviewer says that 
Reblozyl is not medially reasonable and necessary for the enrollee in this case. Our physician reviewer found 
that Reblozyl is FDA approved for the treatment of anemia failing an erythropoiesis-stimulating agent and 
requiring 2 or more RBC units over 8 weeks in adults with very low- to intermediate-risk myelodysplastic 
syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring 
sideroblasts and thrombocytosis (MDS/MPN-RS-T).  Luspatercept is not indicated for use as a substitute for 
RBC transfusions in patients who require immediate correction of anemia. There are no off-label indications or 
support from the medical literature. There is no documentation of this patient receiving any blood transfusions 
to date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
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 
March 17, 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 
enrollee's condition. 
 
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. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 3, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the medical services. You say that the physician provided medically necessary 
services to the enrollee in good faith. The Plan denied your request. The Plan says no necessity for an out-of-
network provider has been documented. 
 
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 January 3, 2020 
by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 14, 
2019 through July 17, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found upon review of the provided notes, the signs and symptoms as well as the computed 
tomography (CT) findings and labs suggest a non-infectious cause of the patient's pain and the CT scan did not 
show clear signs of obstruction, suggesting a likely noninfectious colitis such as ischemic colitis. The patient's 
vitals were stable besides pain which could have been controlled and monitored in the emergency department 
(ED) under observation status. Surgery and gastrointestinal (GI) could have been consulted under observation 
status. There was no planned procedure or treatment besides medication management and pain control at the 
time of admission. Therefore, there was no reasonable expectation that the patient would have required at least 
a two-midnight stay in the hospital based on the documentation provided. 
 
 
 
 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided to the enrollee from July 14, 2019 through July 
17, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the zinc air batteries for use with cochlear implant device provided on 
February 13, 2020. 
 
You asked the Plan to pay for the 180, 3-month supply of batteries. You say that the enrollee needs 60 units a 
month for the external speech processor. The Plan denied your request. The Plan says that excess units are 
denied according to CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the batteries have been met. Therefore, we decided that the Plan has to pay for the zinc air batteries 
for use with cochlear implant device provided on February 13, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 31, 2020 
to February 18, 2020 and from February 22, 2020 to February 29, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 31, 2020 to February 18, 2020 
and from February 22, 2020 to February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on September 18, 2019. 
 
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 procedure codes 64483 and 64484 are not supported. 
 
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 64483 is injection(s), anesthetic agent and/or steroid, 
transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level. The 
definition of code 64484 is injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for 
primary procedure). 
 
We find that CPT codes 64483 and 64484 are not supported in the medical record. Specifically, there is no 
documentation of a transforaminal epidural steroid injection with imaging guidance, lumbar or sacral, single 
level, to support code 64483. There is no documentation of an injection to each additional level to support code 
64484. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the injection services rendered on September 
18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and bitewings 
provided on June 2, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and bitewings. You say that you are 
experiencing severe swelling, bleeding, and pain due to inflamed gums. The Plan denied your request. The Plan 
says the benefit maximums for the time period or occurrence have been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, oral exams are limited to 1 every 6 
months, and bitewings are limited to up to four bitewings per 12 months. The record shows that you received a 
periodic oral evaluation and bitewings on May 14, 2020, and your oral exams and bitewings benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal 
evaluation and bitewings provided on June 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copay for the transthoracic echocardiography testing 
provided on January 28, 2020. 
 
You asked the Plan to reduce the copay for the testing services. You say that you should only have a $20 
copay. The Plan denied your request. The Plan says cost share is a contractual obligation, and cannot be 
waived. 
 
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 $150 
copay for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $150 copay for the testing services. The services fall within the outpatient 
diagnostic tests 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 reduce the copay for the transthoracic 
echocardiography testing provided on January 28, 2020.
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 the records provided support the need for the 
requested SNF care. The Plan denied your request. The Plan says the clinical information provided does not 
support the medical necessity of SNF care. 
 
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, was treated for pain with effect, and had clear lungs. The enrollee received 
physical therapy and occupational therapy in the SNF. Upon evaluation, the enrollee was at a contact guard to 
minimal assist level with functional mobility, including gait to 20 feet with a cane. The enrollee required 
varying assist with activities of daily living. There are not currently any identifiable skilled nursing service 
needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. 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.