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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on July 2, 2021. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
we had not submitted the claim within the timely filing limit. You also say  we did respond to the call on time 
and provided one to one medical necessity services to your beneficiary. The Plan denied your request. The Plan 
says the claim was not received within the allowed 12 months from the date of service. 
 
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 ambulance service, basic life support, non-emergency transport was not 
filed until November 23, 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 ambulance 
service, basic life support, non-emergency transport provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on August 15, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that this was medically necessary and should be 
covered. This plan has paid this provider in the past. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth visit 
provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet all three criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided from August 10, 2022, to 
August 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a manual wheelchair. You say that this was medically necessary and should be 
covered. We have forwarded medical documentation to help get an approval. The Plan denied your request. 
The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an 
out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 manual wheelchair provided from August 10, 
2022, to August 29, 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 nursing facility services provided on October 27, 2022. 
 
You asked the Plan to pay for nursing facility services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility services 
provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and x-rays of the jaw provided on July 09, 
2021, to July 19, 2021. 
 
You asked the Plan to pay for the office visits and x-rays of the jaw. You say that a referral was made for the 
requested services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits and x-
rays of the jaw provided on July 09, 2021, to July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 07, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered. 
 
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 office visit provided on December 07, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 22, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bitewings (D0270), and 
panoramic film (D0330) provided on October 19, 2022, and November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to find a new provider and you should 
not be responsible for the charges. The Plan denied your request. The Plan says your benefit for the panoramic 
film and bitewings has already been exhausted. Also, the denial of payment for the limited oral evaluation is 
correct, because it is not covered by the Plan. 
 
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, certain limitations apply. The record 
shows your benefit for the panoramic film was exhausted on the date of service of November 18, 2020, and 
your benefit for the bitewings was exhausted on the date of service of October 19, 2022. The limited oral 
evaluation is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation (D0140), bitewings (D0270), and panoramic film (D0330) provided on 
October 19, 2022, and November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and an 
outpatient surgery provided on September 6, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and an outpatient surgery. 
You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged 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 20% 
coinsurance for Medicare Part B prescription drugs and a $325 copayment for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $325 copayment 
for an outpatient surgery. The total allowed amount for the prescription drugs is .58. You are being asked to 
pay .12 (.58 x 20% = .12). You are being asked to pay $318.42 which is less than the required amount of $325. The total amount you are being asked to pay for both services is $318.54 ($.12 + $318.42 = $318.54). 
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 share for Medicare Part B prescription drugs and an outpatient surgery 
provided on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from September 8, 
2022, to September 13, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that the member never left the hospital 
but continued inpatient treatment and additional required care of PT was added to the current daily care plan. 
The Plan denied your request. The Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment per day for days 1-5 and $0 copayment for days 6 and beyond for each Medicare-
covered inpatient admission.  
 
 
  The enrollee has been asked to pay a total copayment of $1,250 for an IRF stay ($250 per day x 5 days = 
$1,250). This item/service 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 IRF stay provided from September 8, 2022, to September 13, 
2022.  
 
Your complaint about the inpatient hospital copayment starting over when the enrollee entered IRF care is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on June 10, 2022. 
 
  You asked the Plan to pay for the rotary wing air transport and mileage. You say that you would like this claim 
to be reprocessed in accordance with the enrollee's in-network benefit for emergent air ambulance 
transportation for payment. The Plan denied your request. The Plan says the information provided does not 
support the criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport and mileage. 
Our reviewer says that the rotary wing air transport and mileage was not medically reasonable and necessary 
for the enrollee. Our physician reviewer found while the transfer itself appears to have been medically 
necessary, the enrollee appears to have been medically stable, and the transport does not appear to have been to 
the closest appropriate facility. There is no documentation as to why the enrollee was transported to a more 
distant facility. Our reviewer found that as such, the transport was not reasonable. 
 
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 rotary wing air transport and mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage 
(A0436) provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need to know if you will be receiving 
your SSBCI benefit as soon as possible. The Plan denied your request. The Plan says there is no documentation 
that you meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on October 11, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from July 30, 2022, to August 3, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told that this 
copayment would be waived. The Plan denied your request. The Plan says this cost sharing was charged 
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 $280 
copayment per day, days 1 to 7, for in-network inpatient hospital care. 
 
You have been asked to pay a $840 copayment for the inpatient hospital stay ($280 x 3 days = $840). This 
item/service 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 by an in-network provider from July 30, 2022, to August 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service November 6, 
2022. 
 
You asked the Plan to pay for procedure code 99051. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99051 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service November 6, 2022.