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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 31, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you were never informed to put the zip code in the authorization box before April 22, 2022. You also say that 
this is your first time billing this plan, and you are unaware of the requirements. The Plan denied your request. 
The Plan says you are past the timely filing limits for the corrected claim. 
 
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 non-emergency ambulance transportation and ground mileage was not 
filed until March 19, 2022. 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 non-emergency 
ambulance transportation (A0428) and ground mileage (A0425) provided on December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 15 routine transportation trips. 
 
You asked the Plan to pre-approve an additional 15 routine transportation trips. You say that you need 
transportation to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 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 an additional 15 routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that the enrollee requires additional visits. 
You say that the enrollee is still in a lot of pain and having issues. You also say that additional visits are 
necessary to avoid surgery. The Plan denied your request. The Plan says that additional visits are not medically 
necessary. 
 
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 pre-approve 8 additional PT visits. Our reviewer 
says that the 8 additional PT visits are medically necessary. Our physician reviewer found 8 sessions would be 
typically approved with re-evaluation necessary for advanced disk disease in lumbar region. The reviewer also 
found that the enrollee also has cervical disk disease, thus 16 sessions would be more consist with medical 
literature. Therefore, the reviewer found that 8 additional physical therapy sessions are 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 8 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve 8 additional physical therapy (PT) visits.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 18, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the services. The 
Plan denied your request. The Plan says the procedure code is inconsistent with the place of service. 
 
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 99203 is not recognized by the outpatient prospective payment system (OPPS) when 
submitted on an outpatient hospital bill. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the office visit provided on May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you will only use what you have in your office 
stock. The Plan denied your request. The Plan says there has not been a trial and failure of Euflexxa. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file, and Medicare rules. The Plan requires a trial of Euflexxa before they will approve the 
requested drug. The documentation does not show that the enrollee has tried and failed the Plans preferred 
drug. There is no documentation that shows the Plans required drug is likely be less effective or likely have 
adverse effects for the enrollee. Based on this information, we decided that Medicare rules for coverage of 
Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nailbed removal performed on May 19, 
2022. 
 
You asked the Plan to waive the copayment for the nailbed removal. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says this claim was processed 
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 a $150 
copayment for in-network outpatient hospital surgery services. However, you have only been asked to pay 
$138.06, which is less than the $150 copayment amount. 
 
You have been asked to pay $138.06 for a nailbed removal. A nailbed removal falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the nailbed removal performed 
on May 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left shoulder for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that imaging requires six weeks of provider-directed treatment to be completed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the x-rays revealed 
degenerative changes in the left shoulder. A detailed physical exam of the left shoulder revealed very positive 
Hawkins and Neer tests, which indicate rotator cuff pathology. Hence, the criteria for MRI left shoulder 
without a trial of physical therapy have been 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 the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the left shoulder for the enrollee.  
 
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 pay for an office visit provided on December 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this member significantly benefited from this 
service. The Plan denied your request. The Plan says at the time of service, this provider was out-of-network. 
The Plan also says that there are no referrals in the system and services were not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 27, 2021, 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 tendon injection (20550) provided on April 11, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the tendon injection. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a tendon injection (20550) provided on April 11, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
October 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records validate multiple billing 
for code 99214. The Plan denied your request. The Plan says an excessive number of units was reported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99214 was billed twice on the same day by the same physician. Instead of billing 
separately, the physicians should select a level of service representative of the combined visits and submit the 
appropriate code for that level. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services provided on October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit, excision of nail, and 
debridement of nail(s) provided on March 16, 2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit, excision of nail, and debridement of nail(s). You 
say that you are requesting reconsideration stating to please review the attached medical records proving 
medical necessity and reprocess this claim for payment. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit, excision of nail, 
and debridement of nail(s) provided on March 16, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for office visit on January 21, 2022, to 
February 11, 2022. 
 
You asked the Plan to waive the cost sharing for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 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 45% 
coinsurance for out-of-network annual wellness visit. If youve had Part B for longer than 12 months, you can 
get an annual wellness visit to develop or update a personalized prevention plan based on your current health 
and risk factors. Our plan will cover the annual wellness visit once each calendar year. You must pay a 45% 
coinsurance, after your $750 plan deductible, for Medicare-covered primary care physician (PCP) services 
(including Medicare-covered telehealth services and urgently needed services). Covered services include 
Medically necessary medical care or surgery services furnished in a physicians office, certified ambulatory 
surgical center, hospital outpatient department, or any other location. On January 21, 2022, the provider billed 
in the amount of $210 and the allowed amount is a $123.29 deductible. On February 11, 2022, the provider 
billed in the amount of $230 and the allowed amount is $135.28. $135.28 x 45% = $60.88. $123.29 + $60.88 = 
$184.17. Therefore, results in the total cost sharing amount of $184.17. 
 
You have been asked to pay a 45% coinsurance and a $123.29 deductible for office visit. Office visits fall 
within the Annual wellness visit and 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 cost sharing for office visit on January 21, 2022, to February 
11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that if this is not taken care of the 
situation could lead to adrenal failure. The Plan denied your request. The Plan says you do not meet criteria for 
inpatient hospital level of care and the needed testing can be performed as outpatient. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital level of care are 
met in this case. Our physician reviewer found you were not having nor were expected to have an acute adrenal crisis or other condition that might warrant your necessary hospital services to span at least 2 midnights. 
 
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 pre-approve acute inpatient hospital level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for the services provided. You say that this code is separately payable to the main 
procedure. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on March 30, 2022, by the 
out-of-network provider. 
 
You asked the Plan to pay for the physician service. You say that you were not informed that the provider was 
out-of-network. You say that you may require surgery. You also say that this is the only insurance that you 
have. The Plan denied your request. The Plan says the claim processed 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 50% of 
the Medicare-allowed amount for Specialist Visit.  
 
You have been asked to pay 50% of the Medicare-allowed amount for the physician service that you received 
out-of-network. The physician service falls within the Specialist Visit 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 pay for the office visit (99215) provided on March 30, 2022, by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hammertoe correction (28285) provided on March 2, 
2022. 
 
You asked the Plan to pay for the hammertoe correction (28285). You say that the Payment Indication List 
provided by CMS does not exclude payment of an assistant surgeon for CPT code 28285. You say that the 
denial should be overturned, and the claim correctly reprocessed for payment. The Plan denied your request. 
The Plan says an assistant surgeon may not be paid for this procedure. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 28285. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
hammertoe correction (28285) have not been met. Therefore, we decided that the Plan does not have to pay for 
the hammertoe correction (28285) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses and evaluation provided on November 12, 
2021. 
 
You asked the Plan to pay for the contact lenses and evaluation. You say that it has been more than 13 months 
since your last rebate check. The Plan denied your request. The Plan says your allowed benefit has been met. 
 
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 up to $100 per calendar year for routine contacts or eyeglasses. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $100 for the contact lenses and 
evaluation provided on March 13, 2021. Based on this information, we decided that the Plan's rules for 
coverage of the contact lenses and evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for the contact lenses and evaluation provided on November 12, 2021.