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

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on September 19, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell between the bed and your wall. You 
say that your daughter helped you up. You say that you were confused. You also say that your daughter called 
911. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 September 19, 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, no 
transport, (A0998) provided on September 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 1, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on January 12, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on November 30, 
2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service does not meet the benefit criteria. 
 
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, bitewing x-rays are not covered in the 
same year as a full mouth set of x-rays (D0210). The record shows that you received a full mouth set of x-rays 
(D0210) on January 20, 2021 and you therefore could not receive covered bitewing x-rays during the 2021 plan 
year. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on 
November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient hospital observation on 
February 7, 2022, to February 8, 2022. 
 
You asked the Plan to waive the copayment for Outpatient hospital observation. You say that youre 
questioning the total amount. You don't know what the bill is for and why such a large amount. 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. Your 
contract with the Plan says that there is a $750 deductible and $125 copayment which applies to Outpatient 
hospital observation. At the time this claim was paid, $0 of the deductible had been met. The allowed amount 
of this claim is $2,100, resulting in a $750 deductible amount which meets the deductible for 2022. After the 
deductible is met, a $125 copayment was applied to the claim. Therefore, your total cost-sharing amount is 
$875.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category Outpatient 
hospital observation. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$750 deductible and $125 copayment which applies to Outpatient hospital observation.  This cost sharing is a contractual obligation that had not been met at the time Outpatient hospital observation 
was received on February 7, 2022, to February 8, 2022. Therefore, we decided that the Plan does not have to 
waive the copayment for Outpatient hospital observation on February 7, 2022, to February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in -network practitioner services provided 
on March 5, 2021, and March 19, 2021. 
 
You asked the Plan to waive the copayment for in network practitioner services. You say that that you are 
being charged out of network and want the charges to be in- network. The Plan denied your request. The Plan 
says the copay 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 $15 
copayment for in-network primary care provider office visit. 
 
You have been asked to pay $15 copayment for in network practitioner services. In- network practitioner 
services 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 in -network practitioner services provided on March 5, 
2021, and March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the burr hole with evacuation procedure, anesthesia, and 
initial hospital care provided on September 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the burr hole with evacuation procedure, anesthesia, and initial hospital care. 
You say that the service was provided in an emergency situation and should be covered. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider at issue in this case is not a network provider with the Plan. 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 burr hole with evacuation procedure, anesthesia, and initial hospital care. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee could 
not have foreseen requiring any of the services rendered prior to leaving his service area. The record shows that 
the neurosurgery services rendered could have been delayed. However, medical records were not submitted 
from the out-of-area emergency room, hospital, neurosurgeon, or anesthesiologist regarding the emergency 
surgical evacuation of the subdural hematoma. This means that services cannot be verified. 
 
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 burr hole with evacuation procedure, anesthesia, and initial hospital care 
have not been met.  
 
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 pay for the burr hole with evacuation procedure, anesthesia, and 
initial hospital care. Therefore, we decided that the Plan does not have to pay for the burr hole with evacuation 
procedure, anesthesia, and initial hospital care provided on September 15, 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 laboratory services provided on February 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you switched over to the Plan and they 
assigned you a physician to see. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there are no documents showing who the referring provider is. Therefore, they could not 
determine the medical necessity and if the service is available with an in-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 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 laboratory services provided on February 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve MPI test. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-
network with the Plan and this test can be performed by an in-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 
myocardial perfusion imaging (MPI) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction of begin lesions provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for the destruction of begin lesions. You say that you were 
questioning why your lab work copayment was so high. You also say you had the same procedure in 
September 2021. 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 $350 
copayment for outpatient surgery at an outpatient hospital facility.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $196.49, which is less than the $350 copayment for the destruction of begin lesions. The 
destruction of begin lesions falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the destruction of begin lesions provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in- network outpatient services on 
November 1, 2021 
 
You asked the Plan to waive the copayment for in- network outpatient services. You say that you are being 
charged out of network and should be charged in network. The Plan denied your request. The Plan says the 
copay 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 $295 
copayment for Outpatient hospital services.  
 
  
You have been asked to pay $295 copayment for in- network outpatient services. In- network outpatient 
services falls within the Outpatient hospital 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 in- network outpatient services on November 1, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head or brain (CPT 70450). 
 
You asked the Plan to pre-approve a CT scan of the head or brain. You say that a CT scan is medically 
necessary. The Plan denied your request. The Plan says a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the head or brain. Our 
reviewer says that a CT scan of the head or brain is not medically necessary. Our physician reviewer found no 
history of trauma. The notes indicate mild cognitive impairment, but the enrollees memory was described as 
"ok" in the notes. There was no Mini-Mental State Exam (MMSE) assessment or other objective testing to 
document memory loss and cognitive impairment. Medical necessity of the requested CT of the brain has not 
been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the head or brain have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the head or brain (CPT 70450).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that the ECG should have been included with 
the office copayment. 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 $20 
copayment for non-radiological diagnostic services, including ECGs.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of 12.89, which is less than the $20 copayment for an ECG. An 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 November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cardiac catherization provided on 
November 5, 2021. 
 
You asked the Plan to waive the coinsurance for a cardiac catherization. You say that this procedure was pre-
approved and do not think the claim was paid correctly.  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 20% 
coinsurance for in-network outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$930.40, which is 20% coinsurance of the allowed amount for a cardiac catherization ($4,651.99 allowed amount x 20% coinsurance = $930.40). A cardiac catherization falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a cardiac catherization provided on November 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient rehabilitation stay provided 
from August 20, 2021, to September 10, 2021.  
 
You asked the Plan to waive the coinsurance for an inpatient rehabilitation stay. You say that a social worker 
gave you a list of in-network facilities to choose from. You also say that you never would have chosen an out-
of-network facility as you cannot afford the cost. 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 20% 
coinsurance for an out-of-network inpatient rehabilitation stay.  
 
 You have been asked to pay $6,535.20, which is less than the 20% coinsurance of the allowed amount for an 
inpatient rehabilitation stay. An inpatient rehabilitation stay 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 coinsurance for an inpatient rehabilitation stay provided from 
August 20, 2021, to September 10, 2021.   
 
Your complaint about the social worker giving you incorrect information about the facilities network status 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on December 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the provider is in-network, and the claim was 
processed as out-of-network.  The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the laboratory work in this appeal. The Plan did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record shows CPT code 36415 was billed which means the provider had the opportunity to confirm 
insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the 
laboratory work provided on December 20, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Morphine Sulfate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Morphine Sulfate for the 
enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.