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

We decided that the Plan has to pay for the BLS emergency ambulance (A0429) ground mileage (A0425) 
provided September 26, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that this enrollee had two 911 emergencies in the 
same day. Please be advised there are numerous ways to differentiate between the two trips to prove they are 
not duplicate. The Plan denied your request. The Plan says that this is a duplicate service of a previously paid 
claim. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
In this case, the submitted documentation clearly shows that the enrollee was provided emergency ambulance 
services twice on the same day. The ambulance provider has submitted the two Patient Care Reports (PCR) 
showing that per Run number 72053, the enrollee's first emergency ambulance was provided at 9:30 am. The 
second emergency ambulance, per Run number 72210, was then provided at 3:30 pm. Therefore, verifying that 
the ambulance service provided is not a duplicate. Based on this information, we decided that Medicare rules 
for coverage of the ambulance service have been met. Therefore, we decided that the Plan has to pay for the 
BLS emergency ambulance (A0429) ground mileage (A0425) provided September 26, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 26, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the chemotherapy services. You say that you would like reconsideration because 
these services were medically necessary. The Plan denied your request. The Plan says utilization of network 
providers is required when possible and available. 
 
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 26, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 13, 2020, to May 16, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you feel that it should only count as one stay, not three separate ones. The Plan denied your 
request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment per day for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient hospital stay from May 13, 2020, to May 16, 2020. Therefore, the enrollee is 
responsible to pay a $275 copayment for days 1-3 (May 13, 2020, to May 15, 2020). $275 (copayment) x 3 
(inpatient days) = $825. 
 
The enrollee has been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An 
inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an inpatient hospital stay provided from May 13, 2020, to May 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 1, 2019 to February 27, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the billed claim is for a non-participating Home 
Health provider and the RAP claim was not submitted. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not include any evidence that a RAP was submitted. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from February 1, 2019 to February 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a CT scan, thoracentesis and a MRA 
provided from March 11, 2020, to April 3, 2020. 
 
You asked the Plan to waive the copayments for a CT scan, thoracentesis, and an MRA. You say that the 
charges are more than 20% coinsurance and you disagree with 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 a $200 
copayment for complex radiology. Your contract with the Plan also clearly says that you must pay a $350 
copayment for outpatient hospital facility services. 
 
You received a CT scan on March 11, 2020. Therefore, you are responsible to pay the $200 copayment.  
 
You received thoracentesis on March 13, 2020. Thoracentesis is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the $350 copayment.  
 
You received a MRA on April 3, 2020. Therefore, you are responsible to pay the $200 copayment.  
 
The total amount you owe is: $200 + $350 + $200 = $750.   
 
 
 
You have been asked to the total copayment amount of $750 for a CT scan, thoracentesis, and an MRA. A CT 
scan and an MRA fall within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. Thoracentesis 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 copayments 
for a CT scan, thoracentesis and a MRA provided from March 11, 2020, to April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on May 21, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 bone 
replacement graft for ridge preservation (D7953) provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition supplies (B4185, B4199, B4220 and 
B4224) provided on December 25, 2019 through December 30, 2019. 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not include an itemized shipping/billing invoice to indicate the specific supplies or a proof of delivery. 
 
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 the billed supplies on the itemized delivery invoice. Additionally, the record does not 
include a proof of delivery 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 parenteral nutrition supplies (B4185, B4199, B4220 and B4224) provided on December 25, 2019 
through December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided April 30, 2020. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says payment for this visit was included in the global surgery payment for the related 
procedure. 
 
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 99214 is not supported in the medical record. Specifically, the record shows this visit 
was a follow up to a surgical procedure. Payment for this visit was included in the global surgery payment. 
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-ray (D0220), the drugs and medicaments 
(D9630), and the unlisted oral surgery procedure (D7999) provided on May 6, 2020. 
 
You asked the Plan to pay for the x-ray, medications, and unlisted surgery. You say that your filling had fallen 
out. You say that you received 2 statements from the plan showing you did not know anything. You say that 
you received a third statement stating you owed $1,344. You also say that you should not have to pay this 
much. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service. The Plan 
says drugs and medicaments is not listed as a covered service. The Plan also says unlisted oral surgery is not 
listed as a covered service. 
 
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 periapical 
x-ray (D0220), the drugs and medicaments (D9630), and the unlisted oral surgery procedure (D7999) provided 
on May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging (78815) provided on April 1, 2020. 
 
You asked the Plan to pay for the PET imaging. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 78815 was not billed with an 
appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815-26-PI is not supported in the record. Specifically, Medicare has a list of 
appropriate diagnosis codes that may be used. The diagnosis code billed, C79.51, is not included on the list of 
appropriate codes. Based on this information, we decided that Medicare rules for coverage of the PET imaging 
have not been met. Therefore, we decided that the Plan does not have to pay for PET imaging (78815) provided 
on April 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient stay provided from March 23, 2020, through 
March 31, 2020. 
 
You asked the Plan to pay for the inpatient stay. You say that the enrollee was not enrolled in hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 22, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient stay 
provided from March 23, 2020, through March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 28, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ultrasounds provided by a participating 
provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should only have to pay a $100 
copayment. The Plan denied your request. The Plan says the correct copayments have 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 $100 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests/in-network.  
 
You have been asked to pay less than a $100 copayment for each ultrasound. The total amount you are being 
asked to pay is $199.92 (99.96 x 2 ultrasounds = $199.92). Evidence was provided that an ultrasound was 
performed on each breast; therefore, the correct copayments have been applied. An ultrasound falls within the 
outpatient diagnostic tests/other outpatient diagnostic tests/in-network 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 two ultrasounds provided by a participating provider on May 11, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a first outpatient office visit (99203) and destruction of 
premalignant lesion (17004). 
 
You asked the Plan to pay for the office visit and destruction of skin growth.. You say that you were told the 
services would be covered minus the copay. The Plan denied your request. The Plan says Physicians and 
practitioners that have opted out or are otherwise excluded from the Medicare program are not covered under 
any condition 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
first outpatient office visit (99203) and destruction of premalignant lesion (17004).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on March 27, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 forthe Guardant360 panel rendered on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 26, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal tunnel surgery (64721) provided on March 26, 2020. 
 
You asked the Plan to pay for the carpal tunnel surgery. You say that you would like reconsideration because 
this provider rendered services on a medically necessary basis. The Plan denied your request. The Plan says no 
provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider 
or supplier is enrolled in the Medicare program. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for carpal tunnel surgery (64721) 
provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 30, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 6 allotted trips for the 
2020 calendar year and additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 6 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.