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

We decided that the Plan does not have to pre-approve a panniculectomy including the associated procedures, 
and inpatient hospital admission for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a panniculectomy is considered to be experimental and 
investigational for minimizing the risk of hernia formation or recurrence. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 requested services are not considered medically reasonable and necessary in this case. The record indicates 
that the enrollee has had multiple abdominal surgeries. The record indicates that the enrollee was being 
considered for panniculectomy and an incidental ostomy site hernia was found. The record does not indicate 
that the enrollee has intertrigo not responsive to conservative therapy. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
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 a panniculectomy including the associated procedures, and inpatient hospital admission for 
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan. 
 
You asked the Plan to pre-approve Zioptan. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral nerve stimulation. 
 
You asked the Plan to pre-approve sacral nerve stimulation. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered only for those 
indications established in the applicable NCD. 
 
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 sacral nerve stimulation. Our reviewer 
says that the requested sacral nerve stimulation is not medically reasonable and necessary in this case. Our 
physician reviewer found that to qualify for sacral nerve stimulation, the enrollee must be able to demonstrate 
adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly 
evaluated. The medical records do not include a voiding diary. The enrollee must fail a trial of behavior 
modification. The records do not indicate whether a course of behavior modification has been tried. As such, 
the requested sacral nerve stimulator for urinary incontinence is not medically reasonable and necessary 
according to the coverage criteria established in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral nerve stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacral nerve stimulation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray services (71046, Q0092, R0070) provided on May 
16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the X-ray services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there is no record of prior authorization being made by the member's 
primary care physician for these services provided by an OON 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 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 X-ray services (71046, Q0092, R0070) 
provided on May 16, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 21, 2020. 
 
You asked the Plan to pay for the lab services. You say that the denial was reached by mistake. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the claim billed a place of service as an independent 
laboratory. The records provided do not show that the sample was obtained at an independent laboratory. 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 August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic testing provided on June 14, 2021. 
 
You asked the Plan to pay for the molecular genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The molecular genetic testing at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the molecular genetic testing provided on June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(A0429) with a QL modifier, provided on December 31, 2020. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with a QL 
modifier. The Plan denied your request. The Plan says because the member was not actually transported by 
ambulance, this expense is not covered by the member's benefit. 
The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. 
Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and 
destination modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance service, basic life support, emergency transport (A0429) with a QL modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
emergency transport (A0429) with a QL modifier, provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99203) provided on March 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(E/M) (face-to-face) service is provided on the same day to the same patient by the same physician or more 
than one physician in the same specialty in the same group, only one evaluation and management service may 
be reported unless the evaluation and management services are for unrelated problems.  
 
We looked at the file and Medicare rules. In this case, the records show that more than one E/M was billed on 
the date of service in question by providers of the same specialty within the same group practice. As such, only 
one E/M service is payable for this date of service. 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 
services (99203) provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
procedure you had at an outpatient hospital facility on November 30, 2020. 
 
You asked the Plan to waive the copayment for the EGD procedure. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $275 
copayment for outpatient surgery at a hospital.  
 
You have been asked to pay a $275 copayment for the EGD procedure. The EGD procedure falls within the 
outpatient surgery at a hospital 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 esophagogastroduodenoscopy (EGD) procedure you had at an outpatient hospital facility on November 30, 
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on April 29, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you had a procedure at the 
urgent care center on April 26, 2021.  You were told that you had to return to the urgent care to have the 
packing removed from your wound.  You stated that you were told you would not be required to pay another 
copayment when you returned. The Plan denied your request. The Plan says you were charged this copayment 
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 $45 
copayment for urgently needed care visits.  
 
You have been asked to pay a $45 copayment for the urgent care visit. This copayment applies each time you 
visit the urgent care center, regardless of the reason for the visit. 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 urgent care visit you had on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87581) provided on October 9, 
2020. 
 
You asked the Plan to pay for laboratory services. You say that these tests were ordered by the physician. The 
Plan denied your request. The Plan says these tests were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87486, 87581) provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on March 29, 
2021. 
 
You asked the Plan to pay for the resin-based composite. You say that you believe by getting this filling you 
were able to save your tooth from extraction. You also say that you feel this should be covered because it is 
maintenance to keep a healthy mouth and keep your own teeth. The Plan denied your request. The Plan says 
this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2393) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on May 25, 2021. 
 
You asked the Plan to pay for the crown. You say that you had a cracked tooth that required a cap and the 
benefits were checked prior to receiving dental services. You say that you were informed the Plan would pay 
30% but had to pay the entire bill of $900. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
provided on May 25, 2021.  
  
Your complaint about the system being setup against patients 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: Partially Favorable

We decided that the Plan has to hold you harmless for the routine disposable supplies (A0398). We decided 
that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998).  
 
You asked the Plan to pay for the ambulance response and treatment with no transport (A0998) and routine 
disposable supplies (A0398). You say that you passed out, had a concussion, and were unresponsive so your 
wife called 911. You also say that you were told this was a covered expense. The Plan says that the Medicare 
ambulance benefit is a transport benefit, and if no transport of a Medicare beneficiary occurs, then there is no 
Medicare covered service. The Plan also says that you refused to be transported to an emergency facility. 
 
We decided that the Plan has to hold you harmless for the routine disposable supplies (A0398).  
 
The Plan follows Medicare rules. Medicare rules say that items and services which include but are not limited 
to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and night differential are no longer paid 
separately for ambulance services.  
 
We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare 
rules for coverage have been met. Specifically, ambulance supplies are not separately billable to you because 
the payment for these supplies is included as part of the base rate for the ambulance services. Therefore, we 
decided that the Plan must hold you harmless for Therefore, we decided that the Plan has to hold you harmless 
for the routine disposable supplies (A0398).  
 
We also decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998). 
 
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 May 28, 2021. 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 response and treatment with no 
transport (A0998). 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided on May 26, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound 
provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit you had with an out-of-
network nurse practitioner on June 2, 2021. 
 
You asked the Plan to waive the coinsurance for the out-of-network nurse practitioner services. You say that 
this nurse practitioner is in the same office as your doctor, so it should be processed as in-network. The Plan 
denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that not only is 
the nurse practitioner from whom you received these services out-of-network, the doctor whose care you are 
under in this same office is also out-of-network. 
 
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% 
coinsurance for out-of-network physician and professional services.  
 
You have been asked to pay 50% coinsurance for the out-of-network nurse practitioner services. This provider 
and the doctor with whom they are affiliated are both out-of-network. 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 
coinsurance for the office visit you had with an out-of-network nurse practitioner on June 2, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for phlebotomy services. We decided that the 
Plan does not have to reduce the cost-sharing charges for phlebotomy services to the amount you requested.  
 
You asked the Plan to reduce the cost-sharing charges for phlebotomy services. You say that the blood draw 
should be included with no copayment. The Plan says that the claims were processed correctly and you are 
being charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for phlebotomy services from $121.01, 
to $40.  
 
The health Plan contract says that enrollees must pay a $40 copayment for non-radiological diagnostic services.  
The Plan says that you must pay $121.01 for phlebotomy services. However, phlebotomy services are 
considered a diagnostic procedure and you cannot be asked to pay more than a $40 copayment. Therefore, we 
decided that the Plan has to reduce the cost-sharing charges for phlebotomy services from $121.01 to $40.  
 
We also decided that the Plan does not have to reduce the cost-sharing charges for phlebotomy services 
to the amount you requested.  
 
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 $40 
copayment for non-radiological diagnostic services. Therefore, we decided that the Plan does not have to waive 
the $40 copayment for phlebotomy services. 
 
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.