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

 
We decided that the Plan does not have to pay for non-emergency ambulance services and supplies provided on 
April 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance services and supplies. You say that you had to go 
to the hospital due to an infection in your foot.  You had no other way to get home and needed the assistance of 
the ambulance personnel to get into your home. The Plan denied your request. The Plan says this non-
emergency ambulance transportation to your home was not authorized and wasn't provided by a network 
ambulance provider. The Plan also says that the supplies that the ambulance company billed for are not 
separately payable items. 
 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 rules also say that supplies during an ambulance transport 
are not separately payable. 
 
The provider of the ambulance services in this case is not a network provider with the Plan. You did not have 
prior authorization from the Plan for these ambulance services.  Although these services may have been 
appropriate, the Plan is not obligated to pay for unauthorized, out-of-network services.  Further, Medicare rules 
state that supplies provided by an ambulance company are not separately payable.  As a result, the Plan cannot 
be required to pay for these supplies. Therefore, we decided that the Plan does not have to pay for non-
emergency ambulance services and supplies provided on April 10, 2022, by an out-of-network (OON) 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport provided on 
January 8, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not authorize being 
moved to a different facility.  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 each one-way trip of Medicare-covered ambulance services.  
 
You have been asked to pay a $125 copayment for an ambulance transport. This item/service 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 an ambulance transport provided on January 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on October 28, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you feel that 
you should not have to pay the entire copay 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount is $957.21. The total amount you are being asked to pay is $191.44 ($957.21 x 20% = $191.44). 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 Medicare Part B prescription drugs provided on October 
28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on May 19, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for anesthesia. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 anesthesia provided on May 19, 2021, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for skilled nursing facility (SNF) on June 16, 
2022, to June 29, 2022. 
 
You asked the Plan to waive the coinsurance for skilled nursing facility (SNF). 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 40% coinsurance per day, days 1 to 100 for out-of-network skilled nursing facility (SNF) care. The 
provider billed in the amount of $7,613.27 and the allowed amount is $5,670. $5,670 x 40% = $2,268.00. 
Therefore, results in the total cost sharing amount of $2,268. 
 
 
 
 
 The enrollee has been asked to pay a 40% coinsurance for skilled nursing facility (SNF). This item/service falls 
within the Skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for skilled nursing facility (SNF) on June 16, 2022, to June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colorectal cancer screening (81528) provided on April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you believe Cologuard is a covered service 
for this enrollee and should have been paid at the National Medicare rate established in the Clinical Lab Fee 
Schedule. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before 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 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 colorectal cancer screening (81528) provided on 
April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a dermatological assessment provided on 
June 15, 2022. 
 
You asked the Plan to waive the deductible for a dermatological assessment. You say that this wasn't a 
scheduled appointment, you wanted one in December as your deductible would have been paid by then. 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 $203 
deductible for Physician/Practitioner services, including doctors office visits. You have a $203 deductible on 
certain services, at the time of this visit you had paid $0 towards this amount. 
 
You have been asked to pay a $125.70 deductible for a dermatological assessment. This item/service falls 
within the Physician/Practitioner services, including doctors 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 deductible for a dermatological assessment provided on June 
15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87503, 87632, and 87634 
provided on April 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The test identified with code 87632 at issue in this 
appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 87634] is a column II code to column I code 
87632. This claim has not been billed with an appropriate modifier to bypass the edit.  
 
Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2.  In this case, the MUE for CPT code 87503 is 1. The MAI value for this code is 2. 
You billed 2 units of this code, exceeding the MUE. 
 
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 laboratory services coded 87503, 87632, and 87634 provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient 
basis. All medically necessary care is being provided in the current acute care setting.  
 
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on 
April 27, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 10, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on 
April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for a CPAP machine. 
 
You asked the Plan to pre-approve the battery backup. You say that the battery backup is medically necessary. 
The Plan denied your request. The Plan says power generating equipment is not considered medical in nature 
and is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup for a CPAP machine.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 1, 2022, to May 
30, 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. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with a valid NOA. 
The submitted NOA does not have the correct date of admission. Therefore, we decided that the Plan does not 
have to pay for the home health services rendered from May 1, 2022, to May 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 25, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 lab testing provided on April 25, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from March 25, 2022, to 
March 27, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the inpatient care was medically necessary. The 
Plan denied your request. The Plan says that the Plan has approved the emergency department services 
provided on March 25, 2022 and has approved an observation level of care for dates of services  
March 26, 2022 to March 27, 2022. All subsequent inpatient care was unauthorized post-stabilization care and 
denied by the Plan in accordance with governing Medicare regulations. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
inpatient care was not medically necessary. Our physician reviewer found that the enrollee was a then, 83-year-
old female who presented to the emergency department (ED) of a non-Plan hospital on March 25, 2022 for 
chest pain with new pulmonary embolism, no evidence of heart strain, subsegmental in terms of anatomy; no 
hypoxia. Observation criteria was met. The review indicates that the treating physician did not document  
(in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 
service. Per the review the enrollee was hemodynamically stable in the ED on March 25, 2022. The enrollee 
was stable for ambulance transport with monitoring to a Plan facility for observation/admission level of care 
services. There was no documentation provided necessitating post stabilization care services March 25, 2022, 
to March 27, 2022 at the non-Plan facility. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient care provided from March 25, 2022, to March 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care services on July 4, 2022. 
 
You asked the Plan to waive the copayment for emergency care services. You say that you would like to appeal 
the cost share. 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 $90 
copayment for emergency care services. The copayment of $64.82 you are being charged is correct since the 
amount due is under the normal $90 copayment 
 
You have been asked to pay a $90 copayment for emergency care services. This item/service falls within the 
emergency 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 copayment for emergency care services on 
July 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ultrasound on July 01, 2022 
 
You asked the Plan to waive the coinsurance for ultrasound. 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 20% 
coinsurance up to $75 per day for Medicare-covered diagnostic radiology services. Covered services include, 
but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, 
and CT scan. The provider billed in the amount of $349 and the allowed amount is $128.50. $128.50 x 20% = 
$25.70. Therefore, results in the total cost sharing amount of $25.70. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for ultrasound. 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 
coinsurance for ultrasound on July 01, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved 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 nursing facility care provided on July 26, 
2022, by an out-of-network (OON) provider.