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

 
We decided that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) 
provided on February 9, 2022. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that you want the Plan to pay for 
the service at issue. The Plan denied your request. The Plan says ambulance transport to or from an outpatient 
office or facility for a scheduled appointment is not a Medicare covered benefit. 
 
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 non-emergency ambulance services. Our 
reviewer says that the service at issue was not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van) were contraindicated for 
this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The 
documentation does not support that the ambulance transport on February 9, 2022, was medically reasonable 
and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) provided on 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that no one at the hospital mentioned that a letter of 
referral was required to continue to see the same physicians for the follow-up care and surgery. You say that no 
one mentioned that this might be an issue with the Plan. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
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 an office visit provided on August 10, 2021, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic care on June 14, 2021. 
 
You asked the Plan to waive the copayment for chiropractic care. You say that you are on a fixed income and 
can't afford it. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $15 
copayment for each Medicare-covered chiropractic visit. Covered services include: we cover only manual 
manipulation of the spine to correct subluxation (when one or more of the bones of your spine move out of 
position) if you get it from a chiropractor. 
 
You have been asked to pay a $15 copayment for chiropractic care. Chiropractic care falls within the 
Chiropractic 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 chiropractic 
care on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on April 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the enrollee does not come to the 
lab which means they are not using their out-of-network benefits. You say the participating doctors sends the 
specimen. 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 did not pre-approve the 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The records provided for review do not show that the surgical pathology services were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
services provided on April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on August 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you were not told you needed prior 
authorization. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advanced. 
 
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 outpatient surgery provided on August 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service provided 
on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that due to the 
ongoing crisis, you had less staff and unable to obtain authorization. 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 did not pre-approve the 
telephone evaluation and management service. We found no exception that would require the Plan to pay for 
the telephone evaluation and management service. The records provided for review do not show that the 
telephone evaluation and management service was urgent or emergent. Therefore, we decided that the Plan 
does not have to pay for the telephone evaluation and management service provided on February 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 22, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be held responsible for this bill because the emergency medical technician that serviced you said you did 
not need to go to the hospital. The Plan denied your request. The Plan says this service is not covered. 
 
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 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The medical records show that you stated you did not want to go to the emergency room on this date of service. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on March 15, 2022, to March 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic care. You say that your referral expired on March 14, 2022, and 
you could not see the doctor until March 21, 2022. The Plan denied your request. The Plan says there was not 
an active referral for the dates of service. 
 
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 
chiropractic care. We found no exception that would require the Plan to pay for the chiropractic care. 
Therefore, we decided that the Plan does not have to pay for the chiropractic care provided on March 15, 2022, 
to March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided on 
February 23, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you were never admitted 
and never received a private room so you shouldn't be charged. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for each Medicare covered hospital stay each time you are admitted.  
 
 
 
 
 You have been asked to pay $1,335.38 which is 20% of the allowed amount for inpatient hospital stay. The 
allowed amount is $6.676.89 (20% x $6,676.89=$1,335.38). Inpatient hospital 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 inpatient hospital stay 
provided on February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart with 
quantitative calcium scoring. 
 
You asked the Plan to pre-approve the CT scan with quantitative calcium scoring. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this testing is not 
a covered service according to Medicare. 
 
The Plan must follow Medicare rules. The rules state that quantitative calcium scoring is not a covered service 
and will be denied as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the CT scan with quantitative calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the computed tomography (CT) scan of the heart with quantitative calcium 
scoring.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 31, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered since it 
was just a follow up from your kidney stones. 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 $350 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
 You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided 
on March 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on April 7, 2022. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says a self-
administered drug is not a covered 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 pay for a self-administered drug 
provided on April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare 
guidelines for LTACH admission. The Plan denied your request. The Plan says the criteria for admission to the 
LTACH has not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH 
would add no additional services. With additional time in the current setting, clinical stability can be ensured 
such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but is still somewhat unstable and should 
only require short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as the enrollee is unstable for transfer still and 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cataract surgery. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the service can be provided 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 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-transport ambulance services provided on March 15, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you opted not to go to the 
hospital due to the fear of exposure to COVID-19. You also said that this claim is a financial hardship for you. 
The Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
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 March 15, 2022. 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 non-transport ambulance services provided on 
March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 16, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
hospital would have had difficulty providing services and given your elderly status it would have been 
dangerous to risk exposure to COVID-19. The Plan denied your request. The Plan says this does not meet 
reasonable lay person standard. The Plan also says you were not in an emergent condition and had access to 
their services which would have addressed your medical concerns. 
 
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 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The medical records show that you insisted you did not want to be transported to the hospital. Therefore, we 
decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) 
provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis procedures to be provided by an OON provider. 
 
You asked the Plan to pre-approve dialysis procedures. You say that you do not want to change from the 
current facility and are considering changing Plans. The Plan denied your request. The Plan says you must 
receive care from a network provider. The information received or obtained, does not show that transferring 
your hemodialysis service from one provider to another will affect your health or your condition, or that you 
will need to remain with the current provider for reasons of time and distance from the recommended facility. 
 
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 
dialysis procedures to be provided by an OON provider.