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

 
We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2018. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 19, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on May 23, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 17, 2020 to February 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you qualify for 
financial assistance and this $570 copayment is very stressful for you. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $285 
copayment per day for days 1-7 of a hospital stay.  
 
You have been asked to pay a $285 copayment for each day the inpatient hospital stay. ($285 x 2 days = $570). 
The inpatient hospital stay falls within the  Inpatient hospital care 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 the inpatient hospital stay provided from February 17, 2020 to February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic services (A0432) provided March 29, 2020 and 
April 10, 2020. 
 
You asked the Plan to pay for the paramedic services. You say that the services should be covered. The Plan 
denied your request. The Plan says the paramedic service does not have a contract with the transporting 
ambulance agency, and therefore is not eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the Paramedic company does not have a contract with the volunteer ambulance 
company that provided the transport services. Therefore, we decided that the Plan does not have to pay for 
paramedic services (A0432) provided March 29, 2020 and April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 20, 2020.
You asked the Plan to pay for office visit. You say that this is your regular family doctor. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan is your secondary payer and cannot pay for this claim until the primary insurance carrier payment information has been received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an Explanation of Benefits (EOB) detailing the payment made by your primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and 
fitting of contact lens (92310) provided February 28, 2020. 
 
You asked the Plan to pay for the vision services. You say that you were under the impression that you were 
only responsible for a $30 copay. You was never aware of any additional service, except for the glaucoma 
screening. The Plan denied your request. The Plan says this service is not covered by Medicare or the plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. The health plan contract says you pay the full cost for any upgrades 
and 100% for any non-covered services. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
prescription of optical and physical characteristics of and fitting of contact lens (92310) provided February 28, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of triamcinolone acetonide provided on 
November 5, 2019. 
 
You asked the Plan to pay for injection. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because peer reviewed 
medical literature considers this use of triamcinolone acetonide as experimental/investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection. Our reviewer says that this 
injection service does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee 
received this injection of triamcinolone acetonide for a diagnosis of seasonal allergies. This use is not approved 
by the Food & Drug Administration (FDA) for the enrollee's diagnosis. This use is also not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection have not been met. Therefore, we decided that the Plan does not have 
to pay for an injection of triamcinolone acetonide provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 18, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not
provided from the billing provider.
The Plan must follow Medicare rules. Medicare rules say that 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.
We looked at the file and Medicare rules. The documentation submitted does not contain medical records from
the billing provider for the date of service in question. Without supporting records, it cannot be determined the
Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab
services provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses warranty you received on January 15, 2020. 
 
You asked the Plan to pay for the warranty. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. While the Plan does cover the eyeglasses you received on the date of 
service in question, the warranty is not a covered benefit. You are responsible for the full cost of the warranty. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses warranty you received on January 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided on February 
24, 2020. 
 
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy services provided on February 24, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for Mohs surgery (17311) performed on February 13, 
2020, and a skin graft to the nose (15260) performed on February 18, 2020. 
 
You asked the Plan to waive the copayment for Mohs surgery and a skin graft to the nose. You say that you 
should not have to pay anything further than already paid by the Plan for care you describe as a 
disappointment. The Plan denied your request. The Plan says that the correct copayments were 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 does not say in clear and accurate terms 
how much you should expect to pay for in-network Medicare-covered outpatient surgery services furnished in a 
physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location.  
 
We looked at your contract with the Plan. Page 88 of the contract says enrollees must pay a $0-$300 
copayment for in-network Medicare-covered outpatient surgery services furnished in a physician's office, 
certified ambulatory surgical center, hospital outpatient department, or any other location. The contract further 
states that the $0 copayment applies to minor procedures. We did not see where the contract provides a 
definition of which procedures are minor. This means that you have no way of knowing when the $0 
copayment applies vs. when the $300 copayment applies. Therefore, the Plan contract does not clearly say how 
much enrollees must pay for in-network Medicare-covered outpatient surgery services furnished in a 
physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. 
This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, 
we decided that the Plan has to waive the copayment for Mohs surgery (17311) performed on February 13, 
2020, and a skin graft to the nose (15260) performed on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the skin lesion paring procedure provided 
on October 28, 2019. 
 
You asked the Plan to reduce the copayment for the skin lesion paring procedure. You say that your deductible 
was met with this visit and you should only be responsible for $11.39 and not a $30 copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $30 
copayment for each Medicare-covered visit in an office of home setting.  
 
You have been asked to pay a $30 copayment for the skin lesion paring procedure. The skin lesion paring 
procedure falls within the ?Podiatry services? benefit category. The record shows you had previously met your 
$200 deductible amount. Therefore, you are responsible for the copayment amount.  
 
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 copayment for the skin lesion paring procedure provided on October 28, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the antigen therapy services (95165) and 
the allergen immunotherapy injection (95115) provided on January 6, 2020. 
 
You asked the Plan to waive the copayment for these services. 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 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 $20 
copayment per visit to a specialist.  
 
You have been asked to pay a $20 copayment for the treatment provided by a specialist. 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 the antigen therapy services (95165) and the allergen immunotherapy 
injection (95115) provided on January 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging test 
provided on January 29, 2020. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging test. You say that you feel 
that the $150 amount for advanced radiology was covered in your initial copayment for your doctor visits. You 
say this individual test should be covered by your supplemental policy. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $150 
copayment for each Medicare-covered advanced radiology services.  
 
You have been asked to pay a $150 copayment for the myocardial perfusion imaging test. The myocardial 
perfusion imaging test 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 the myocardial perfusion 
imaging test provided by on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99212) provided on March 4, 
2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered. The Plan denied 
your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99212) provided on March 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on May 12, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says an S code cannot be listed as the primary, first listed, or principal diagnosis 
code on a claim. 
 
The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official ICD-10-CM Coding Guidelines. 
 
In this case, the primary diagnosis code you used is a sequela code.  
 
We find that the ICD-10 Coding Guidelines states that certain codes should not be reported first since they are 
manifestations of an underlying condition and the underlying condition should be coded first. Based on this 
information, we decided that Medicare rules for coverage of the ambulance service have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance service provided on May 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 21, 2020. 
 
You asked the Plan to pay for the ambulance transport from the skilled nursing home to a physician office. You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulance transport to or 
from an outpatient office is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office for a 
scheduled appointment. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on February 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy and occupational therapy services 
to be provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the physical therapy and occupational therapy services. You say that this 
provider is very close to your home and you are afraid to leave the area where you live due to the pandemic. 
You say you have known these physical therapists since they were little boys and they are very good at their 
jobs. You say that your health issues make it difficult to go far from your home. The Plan denied your request. 
The Plan says the requested services can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available and accessible to your home who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does 
not have to pre-approve the physical therapy and occupational therapy services to be provided by the out-of-
network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scans of the head 
and neck and brain. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that PET scans 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was evaluated on May 8, 
2020 and reported difficulty with language, leg weakness, lightheadedness, difficulty walking, ataxia, and 
frequent falls. They reported no confusion, no memory loss, no decrease in concentrating ability, no change in 
thought patterns, no repeated questioning about recent events, no weakness, no difficulty writing, and no 
speech difficulties. A PET scan has been requested to rule out Alzheimer's disease versus tauopathy. There is 
no documentation of a recent diagnosis of dementia and documented cognitive decline of at least six months. It 
is not documented that the enrollee meets diagnostic criteria for both Alzheimer's dementia and frontotemporal 
dementia. The requested PET scans are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scans of the head and neck and brain.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you would like to appeal the Plan's decision 
to deny coverage and you asked the Plan to reconsider paying for the services. 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 29, 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.