Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on November 30, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services provided on November 30, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the pre-packaged meals and food provided on 
January 1, 2021. 
 
You asked the Plan to reimburse you for the pre-packaged meals and food. You say that you feel that this 
should be covered. The Plan denied your request. The Plan says pre-packaged meals and food is specifically 
excluded under the Weight Management Program benefit. 
 
Medicare generally does not cover weight management services. However, the Plan offers a weight 
management benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. 
 
Though the Plan offers a weight management benefit in excess of Medicare coverage, the pre-packaged meals 
and food are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
reimburse you for the pre-packaged meals and food provided on January 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
3, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was 
called for you due to dizziness. 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 $325 
copayment for each ambulance trip.  
 
You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered by the out-of-network (OON) 
provider on August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the imaging services rendered by the out-of-network (OON) provider on  
August 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and 
inpatient care provided from November 29, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayments for the ER visit and inpatient care. You say that you were being 
treated for COVID-19. 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 $90 
copayment for each emergency room visit. Your contract with the Plan also clearly says that you must pay a $295 copayment for each inpatient stay. 
 
You have been asked to pay a $90 copayment for the ER visit provided on November 29, 2021. The ER visit 
falls within the Emergency Care benefit category. You have also been asked to pay a $295 copayment for the 
inpatient care provided on December 29, 2021. The inpatient care falls within the Inpatient Hospital Care 
benefit category. The total for both visits is $385. 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 copayments for 
an emergency room (ER) visit and inpatient care provided from November 29, 2021, to December 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the trip was only to 
take you to the building across the parking lot for an MRI. You say the charges are unnecessary. 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 $275 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network 
(OON) provider on January 3, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on January 3, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic services provided on December 20, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the chiropractic services. Therefore, we decided 
that the Plan has to pay for the chiropractic services provided on December 20, 2021.  
 
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 laboratory services provided on November 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 10, 2020. 
 
You asked the Plan to pay for the medical services. You say that you believe that all timely filing requirements 
are waived during the COVID-19 pandemic. The Plan denied your request. The Plan says you did not file this 
claim within the required time frame. The Plan follows Medicare rules. The rules say that claims for services 
furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 
The record shows that a claim for the medical services was not filed until January 18, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services billed for procedure code 21501 
for date of service October 2, 2021. 
 
You asked the Plan to pay for assistant at surgery services billed for procedure code 21501. You say that you 
have provided medical records to support payment for this code. The Plan denied your request. The Plan says 
assistant at surgery services are not paid for procedure code 21501. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare uses the payment policy indicators on 
the Medicare Physician Fee Schedule Database (MPFSDB) to determine if assistant at surgery services are reasonable and necessary for a specific procedure code. For procedure codes that have an indicator of "1" in the 
Assistant at Surgery field in the MPFSDB, assistants at surgery may not be paid for these procedure codes.  
Procedure code 21501 has an indicator of "1" in the Assistant at Surgery field in the MPFSDB.  As such, no 
assistant at surgery services can be paid for this procedure code. Therefore, we decided that the Plan does not 
have to pay for assistant at surgery services billed for procedure code 21501 for date of service October 2, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on  
November 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on November 16, 2021.
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 (A0428), and ground mileage (A0425) provided on November 2, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has mad effort to 
obtain a copy of the Explanation of Benefits from the primary plan, but it has not been received yet. As the 
secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on 
November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on the integumentary system 
(00400) provided on October 18, 2021. 
 
You asked the Plan to pay for anesthesia for procedures on the integumentary system (00400). You say that this 
was an outpatient procedure, and the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says the claim was billed with an incorrect place of service. 
 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered 
inpatient, shall, at a minimum, report the inpatient hospital POS. 
 
In this case, the CPT Code Manual definition of code 00400 is anesthesia for procedures on the integumentary 
system on the extremities, anterior trunk and perineum; not otherwise specified. 
 
We find that CPT code 00400 is not supported in the medical record. Specifically, the outpatient place of 
service code was billed but the enrollee was an inpatient on this date of service. Based on this information, we 
decided that Medicare rules for coverage of anesthesia for procedures on the integumentary system (00400) 
have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on 
the integumentary system (00400) provided on October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) 
provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you do not understand why the 
procedure was billed as outpatient. 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 $200 
copayment for outpatient hi-tech diagnostic imaging, including ultrasounds.  
 
You have been asked to pay a $200 copayment for the TTE. The TTE 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 a transthoracic echocardiogram (TTE) provided on September 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided from 
November 29, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that you needed 
treatment for COVID-19 and you needed to keep returning to the hospital. 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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for each ambulance transportation. The file shows a total of 5 
trips from November 29, 2021, to December 29, 2021. The total for all trips is $1,125 ($225 copayment x 5 trips = $1,125). The ambulance transportation 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 copayments for ambulance transportation provided from November 29, 
2021, to December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you provided medically necessary lab services and 
this claim should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the claim was underpaid and 
should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for 
separate reimbursement. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code G0483 for date of service 
August 13, 2020. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment for this service. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code G0483 for date of service August 13, 2020.