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

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is an 84-year-old woman with history of palpitations. At issue is whether the 
requested authorization for placement of an ILR is medically appropriate and necessary. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 10, 
2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that the hospital did not prescribe 
Plavix. You say that if they had there would have been no reason for the ambulance service. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 $200 
copayment per one-way trip, depending upon the Plan in which you are enrolled.  
 
 
 You have been asked to pay a $200 copayment for ambulance transport. The ambulance transport falls within 
the Ambulance 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 ambulance 
transport provided on April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power lift recliner purchased on December 7, 2021. 
 
You asked the Plan to pay for the recliner. You say that this should be paid for. The Plan denied your request. 
The Plan says purchases over $500 require prior authorization. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that services must be provided by providers who are enrolled in the 
Medicare program. 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Additionally, the 
provider is not contracted with Medicare. Therefore, we decided that the Plan does not have to pay for a power 
lift recliner purchased on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra batteries for a power chair. 
 
You asked the Plan to pay for extra batteries for a power chair. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says the provider in this case is not certified by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for extra batteries for a power chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device (E0601) 
positive airway pressure filter (A7038) miscellaneous Durable medical equipment (E1399) purchased 
September 2, 2021. 
 
You asked the Plan to pay for the CPAP device and supplies. You say that you should be reimbursed for the 
CPAP device and supplies. The Plan denied your request. The Plan says the items was purchased from a 
provider who is not certified with Medicare. If you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) 
device (E0601) positive airway pressure filter (A7038) miscellaneous Durable medical equipment (E1399) 
purchased September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 9, 
2021, to December 11, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient services were not medically necessary. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee is a 49-year-old female who presented to the emergency 
department (ED) with vaginal bleeding due to prolonged menorrhagia with clots on and off. She was treated 
with Kcentra in the ED. A blood transfusion was given, and hemoglobin increased to 9.7 without symptoms. 
Her vitals were stable and she was in no acute distress. Based on the low complexity of this case and response 
to early treatment in ED, it was not expected that the enrollee would require hospital services that would likely 
cross 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 the acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from December 9, 2021, to 
December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair seat lift mechanism provided on December 
22, 2020 to March 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 wheelchair seat lift mechanism provided on 
December 22, 2020 to March 1, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on February 7, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that the copayment is too expensive, and you 
cannot afford it. The Plan denied your request. The Plan says the copayment applied 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 $250 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 You have been asked to pay $250 copayment for CT scan. CT scan 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 
computed tomography (CT) scan provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) provided on September 29, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you would like this claim to be reprocessed and the 
misquote to be honored. The Plan denied your request. The Plan says while the treating provider is in the Plan's 
approved hearing aid vendor network, the enrollee did not schedule an appointment or purchase hearing aids 
through the Plan's approved hearing aid program. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are the Plan's approved hearing aid brand.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5261) provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
November 22, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you are on a fixed income and 
cannot afford the bill. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $259.35, which is 20% of the allowed amount for the injection ($1,296.77 allowed 
amount x 20% coinsurance = $259.35). The injection falls within the Medicare Part B Prescription Drugs 
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 coinsurance for a denosumab injection provided 
on November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the  MRI provided on November 23, 2021, 
and December 28, 2021.  
 
You asked the Plan to waive the copayment for the  MRIs. You say that the imaging was done in the wrong 
part of your body resulting in a second MRI done and then it wasn't needed anymore so the charges should be 
covered. The Plan denied your request. The Plan says the copayment applied 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 $85 
copayment for Medicare-covered radiological diagnostic services not including x-rays performed in a 
physicians office or at a free-standing facility 
.   
You have been asked to pay a total of $170 copayment for the MRIs. ($85/MRI x 2 MRIs = $170). The 
MRIs fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the  MRI provided on November 23, 2021, and December 
28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural injection services. 
 
You asked the Plan to pre-approve transforaminal epidural injection services. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the 
first injection directly and significantly provided improvement of the condition being treated may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months. 
 
We looked at the file and Medicare rules. In this case, the record demonstrates that when the repeat injection 
was requested 3 months had not passed after the first injection Based on this information, we decided that 
Medicare rules for coverage of transforaminal epidural injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat transforaminal epidural injection services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 29, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the service should be covered. The 
Plan denied your request. The Plan says the claim was filed untimely. 
 
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 emergency room services was not filed until December 2, 2021. 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 emergency room services provided on 
February 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leadless pacemaker placement (33274) provided on 
September 15, 2021. 
 
You asked the Plan to pay for leadless pacemaker placement. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. The information provided 
does not indicate the enrollee was enrolled in an FDA-approved study. Based on this information, we decided 
that Medicare rules for coverage of leadless pacemaker placement have not been met. Therefore, we decided 
that the Plan does not have to pay for leadless pacemaker placement (33274) provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 10, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. 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 $350 
copayment per day for days 1 to 5 of for Inpatient hospital care.  
 
 
  You have been asked to pay a $1,750 copayment for 5 days of inpatient hospital care ($350 x 5 = $1,750). 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 inpatient hospital care provided from February 10, 2022, to 
February 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two limited ultrasounds of the breast (76642-LT, 76642-RT), 
diagnostic mammography (77066) and breast tomosynthesis (G0279) provided on December 21, 2021. 
 
You asked the Plan to pay for diagnostic imaging services. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says this is a duplicate of another claim which was 
previously paid with no denied services. 
 
The Plan must follow Medicare rules. Medicare rules say that an exact duplicate for institutional claims is a 
claim or claim line that exactly matches another claim or claim line with respect to certain elements. Duplicate 
claims are rejected and do not have appeal rights. 
 We find that this claim is not supported in the medical record. Specifically, the record includes a copy of a 
previously submitted claim which includes the same services (both CPT codes and modifiers) billed on the 
same date by the same provider for the same enrollee. This previously submitted claim has been paid by the 
Plan with no services denied. There is no documentation to support that the enrollee had these services twice on 
the date in question. Based on this information, we decided that Medicare rules for coverage of diagnostic 
imaging services have not been met. Therefore, we decided that the Plan does not have to pay for two limited 
ultrasounds of the breast (76642-LT, 76642-RT), diagnostic mammography (77066) and breast tomosynthesis 
(G0279) provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling services you received from April 2, 2021, to 
April 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the counseling services you received 
from April 2, 2021, to April 21, 2021.