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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport and ground mileage provided on July 4, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the medical records provided support the need for the requested ambulance transport. 
The Plan denied your request. The Plan says the transport does not meet criteria as it was not medically 
necessary. 
 
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 ambulance service, basic life support, 
non-emergency transport and ground mileage. Our reviewer says that the transportation via ambulance from the 
hospital to the enrollee's residence was not medically necessary.  Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport and ground mileage provided on July 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for intrathoracic procedures (code 00537QX) provided on 
April 7, 2022. 
 
You asked the Plan to pay for anesthesia for intrathoracic procedures. You say that this provider is a Certified 
Registered Nurse Anesthetist and a registered, licensed CRNA with your practice. The Plan denied your 
request. The Plan says that the Plan reimburses ASA codes to anesthesia providers only. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof that this provider is not a licensed 
CRNA. Therefore, we decided that the Plan has to pay for anesthesia for intrathoracic procedures 
(code 00537QX) provided on April 7, 2022.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for new lenses in old frames (S0595) provided on August 11, 2022. 
 
You asked the Plan to pay for new lenses in old frames (S0595). You say that you say you went to an 
appointment, the provider checked you out and passed you to the saleswoman. You also say you took your own 
glasses and asked for the cheapest glass they had. The Plan denied your request. The Plan says that the service 
rendered is not a covered benefit under your 2022 Plan. 
 
Medicare rules say that a Plan must disclose to its enrollees in clear, accurate terms all benefits offered under 
the plan, including applicable conditions and limitations. Your contract with the Plan does not say in clear and 
accurate terms that lenses are only covered if they are billed along with new eyeglass frames.  
 
We looked at your contract with the Plan. We do not see where the contract says that the benefit for eyeglass 
lenses is limited to those provided with new eyeglass frames, or that there is an exclusion of coverage for 
lenses when provided for patient supplied frames. This means that the Plan did not follow Medicare rules for 
disclosure of benefit conditions and limitations. Therefore, we decided that the Plan has to pay for new lenses 
in old frames (S0595) provided on August 11, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 12, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 88305 and 88312 
provided on September 19, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 88305 and 88312. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 88305 and 88312 provided on September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient stay provided on August 29, 2022. 
 
You asked the Plan to pay for an acute inpatient stay. You say that this was medically necessary and should be 
covered. This facility is in-network with the Plan. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an acute inpatient stay 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that you need to see this provider every 3 months, and 
they were in-network last year. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283), ultrasound therapy 
(97035), therapeutic exercises (97110), and outpatient office visit (99212) provided from August 30, 2022, to 
September 13, 2022. 
 
You asked the Plan to pay for the electrical stimulation, ultrasound therapy, therapeutic exercises, and 
outpatient office visit. You say that the received treatments are result effective, cost effective, and no 
alternative treatments. The Plan denied your request. The Plan says the requested services are not covered by 
Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (G0283), ultrasound therapy (97035), therapeutic 
exercises (97110), and outpatient office visit (99212) provided from August 30, 2022, to September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a nerve test with a specialist provided on 
June 20, 2022. 
 
You asked the Plan to waive the deductible for a nerve test with a specialist. You say that you do not 
understand these large charges and have never had copays this high for an office visit before. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to physician/practitioner services, 
including doctor's office visits. $365.07 was applied to your $1000 deductible at the time of this visit. This cost 
sharing is a contractual obligation that had not been met at the time a nerve test with a specialist was received 
on June 20, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a nerve test 
with a specialist provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 2, 2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
prior authorization is required and was not obtained. The provider should have verified the member's eligibility, 
health benefits and obtained authorization prior to the services being rendered. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services provided on 
August 29, 2022. 
 
You asked the Plan to waive the copayments for the ambulance services. You say that you do not have a 
copayment for ambulance services. You also say that you thought you had met your maximum out-of-pocket 
expense earlier in the year. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The record shows you had two ambulance trips on August 29, 2022. You have been asked to pay a $250 
copayment for the first ambulance trip. You have been asked to pay $86.05, which is the less than the standard 
copayment for the second ambulance trip.  The record also shows you met your out-of-pocket maximum during the second ambulance trip. You have been 
asked to pay a total of $336.05 for the ambulance services ($250 copayment + $86.05 copayment = $336.05). 
The ambulance transport services fall 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 waive the copayments for the ambulance service provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) podiatrist. 
 
You asked the Plan to pre-approve a consultation. You say that you have been going this provider for a long 
time. You say that you had a referral to this provider from your primary care physician. You also say that you 
are low income. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 confirmed there are 
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 an office visit to be provided by an out-of-network (OON) podiatrist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve this item. You say that the requested item is medically necessary for the 
enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item. Our reviewer says that the 
requested item is not medically necessary. Our physician reviewer found that the enrollee has severe chronic 
obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF). Arterial blood 
gas (ABG) while acutely ill is consistent with mild chronic carbon dioxide retention, although this has not been 
confirmed by the ABG while stable. If that is confirmed, the enrollee may benefit from a bilateral positive 
airway pressure (BiPAP) machine with average volume assured pressure support (AVAPS) during sleep.  This has not been tried and shown to fail. Medicare does not cover a home ventilator when used as a BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that services were medically necessary and related 
to the members diagnosis. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from August 16, 2022 to 
September 6, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the service 
sought or obtained by the member was or will be rendered by a provider who is not under contract with the 
health Plan and has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided from August 16, 2022 to September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 20, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and take-home 
supply of Methadone (G2078) provided on June 22, 2022. 
 
You asked the Plan to pay for the medication assisted treatment and take-home supply of Methadone. The Plan 
denied your request. The Plan says this provider was not certified/eligible to be paid for this procedure/service. 
 
The Plan must follow Medicare rules. Medicare rules say that a registered nurse is a type of provider that 
frequently attempts to enroll in Medicare but is not eligible to do so. 
 
We looked at the file and Medicare rules. Specifically, the documentation shows that this service was provided 
by a registered nurse. Based on this information, we decided that Medicare rules for coverage of the medication 
assisted treatment and take-home supply of Methadone have not been met. Therefore, we decided that the Plan 
does not have to pay for the medication assisted treatment (G2067) and take-home supply of Methadone 
(G2078) provided on June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $125 copayment for MRI. This item/service 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 MRI provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for installation of handrails provided on July 18, 2022. 
 
You asked the Plan to pay for installation of handrails. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for installation of handrails 
provided on July 18, 2022.