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

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance 
transportation (A0428) provided on October 16, 2021. 
 
You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that 
the enrollee had to be moved via sheet lift to and from the stretcher. You also say that the services rendered 
were medically necessary. The Plan denied your request. The Plan says the criteria for coverage is not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ground mileage and non-emergency 
ambulance transportation. Our reviewer says that the documentation does not support that the ambulance 
transport on October 16, 2021 was medically reasonable and necessary for the enrollee. Our physician reviewer 
found the documentation does not support that other means of transport (such as stretcher van) were 
contraindicated for this enrollee. Our reviewer also found that the documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance could provide for safe transport on October 16, 2021.  
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 ground mileage and non-emergency ambulance transportation have not been 
met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on October 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
18, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not know why 
you were charged for a medical visit. 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 $25 
copayment for each specialist visit.  
 
You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine foot care rendered on September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you did not ask for your nails to be cut. The Plan 
denied your request. The Plan says the services are nto covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. 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 routine foot care 
rendered on September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
September 22, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that this was an annual visit and you feel that 
the tests should be included. 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 $0 
copayment for annual exams. Additional cost share may apply for additional services or testing performed 
during your visit. 
 
Your contract with the Plan clearly says that you must pay a $40 copayment for each diagnostic procedure or 
test at a provider's office. 
 
The file shows that while you were seen for an annual exam, you also had additional testing done which is 
subject to cost sharing. Therefore, you have been asked to pay $30.32, which is less than the $40 copayment for 
the ECG. The ECG 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 an electrocardiogram (ECG) provided on 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatrist visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the psychiatrist visits. You say that you have been seeing this provider prior 
to enrolling into the Plan and would like to continue to see this provider. The Plan denied your request. The 
Plan says a list of in-network providers was given to the enrollee that are accepting new patients and have open 
appointments available and provide the same quality of service as an out-of-network provider. 
 
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 who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
psychiatrist visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you are unhappy with the care 
provided during this exam because you were given a wrong prescription. The Plan denied your request. The 
Plan says the records show that you received a medical eye exam on the date in question. This means that this 
claim was processed correctly, and your copayment was assessed in accordance with your contract. Please note 
that the Plan is reviewing your grievance regarding quality of care in a separate case. 
 
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 $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
 
You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the Medicare-
covered eye exams to diagnose and treat diseases and conditions of the eyes 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 eye exam (92014) provided on November 
18, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 enrollees medical conditions are stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. The enrollee will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her reported pain level and decreased level of endurance. Care at the skilled 
nursing facility level appears to be appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 13, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This 
means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on October 13, 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 trips. You say that you have already used 4 of the 6 trips this 
month. You say that there is still a full year ahead. You also say that you are still looking for more surgery after 
this month so you will need additional trips. The Plan denied your request. The Plan says additional trips are 
not covered. 
 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 routine transportation when up to 6 one-way trips.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The file shows that you have 
used 4 of the 6 allowed one-way trips per year. Additional trips cannot be approved. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) reader (K0554) 
and supplies (K0553). 
 
You asked the Plan to pre-approve a CGM reader and supplies. You say that Medicare will pay for the 
requested items for Type 2 diabetics. The Plan denied your request. The Plan says rules for coverage for CGMs 
and related supplies have not been met. 
 
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 indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM reader 
and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) reader (K0554) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement services (11720, G0127) 
provided on October 12, 2021. 
 
You asked the Plan to waive the copayment for the debridement services. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $75 
copayment for Podiatry services.  
 
 
 
 
 
 You have been asked to pay a $61.71 copayment for debridement services, which is less than the $75 stated in 
the Plans contract. Debridement services fall within the Podiatry services 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 debridement services (11720, G0127) provided on October 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (74177) provided on May 
13, 2021. 
 
You asked the Plan to pay for CT scan 74177. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 74177 has a procedure-to-procedure (PTP) edit of 1 with code 74174 so is not separately payable without an 
appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74177 
is a column II code to column I code 74174. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan (74177) provided on May 13, 
2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 you do require physical therapy and occupational therapy services. You are not stable 
to discharge from the acute hospital and you are not stable to transfer to an acute inpatient rehabilitation 
facility. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the in-network provider does not provide 
the proper equipment. The Plan denied your request. The Plan says the in-network provider given was 
contacted and does provide the proper equipment for the enrollee. 
 
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 who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from 
September 7, 2021, through October 21, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you were never told she was 
primarily a marriage counselor. You say that you verified that you were covered for telehealth and that the 
provider took your insurance. The Plan denied your request. The Plan says payment is denied when performed 
by this type of provider. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, a marriage and family 
therapist is not eligible for Medicare payment. Therefore, we decided that the Plan does not have to pay for the 
outpatient mental health services provided from September 7, 2021, through October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you recommend treatment with Keytruda. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because Keytruda is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve Keytruda. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found 
the enrollee had progressed on prior therapy. The requested use of Keytruda is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. This request is not supported by one of the major 
drug compendia or by clinical research appearing 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (CPT code(s): 3078F, 3074F, G0101, 
Q0091) provided on August 23, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services were not authorized by network/primary care providers. 
 
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 the outpatient services (CPT code(s): 3078F, 
3074F, G0101, Q0091) provided on August 23, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible and copayment for magnetic resonance 
imaging (MRI) provided on October 6, 2021. 
 
You asked the Plan to reduce the deductible and copayment for the MRI. You say that you were informed that 
your deductible was met and you would only have the $150 copayment. The Plan denied your request. The 
Plan says the correct amount was applied to your deductible and the correct cost sharing amount was charged. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to reduce the deductible and copayment for falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $300 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been 
fully met at the time the MRI was received on October 6, 2021. The file shows that you had a total of $174.44 
remaining to meet your deductible, which was applied. The remaining amount of $35.01 was applied as the 
copayment, and it is less than the $150 copayment per the EOC. Therefore, we decided that the Plan does not 
have to reduce the deductible and copayment for magnetic resonance imaging (MRI) provided on October 6, 
2021.