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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you could not book 
transportation to your specialist office; you were told it was over the 50-mile one-way for each trip. The Plan 
denied your request. The Plan says your benefit only allows 50 miles one-way. You have exceeded your benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24, 50 miles of driving distance one-way trips per year.  
We looked at your request, the records in the case file, and the rules. Your request of 260 additional miles for 
routine transportation exceeds your benefit maximum allowed for routine transportation. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99153) provided on April 14, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
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 99153 is not supported in the medical record. Specifically, this service has a 
professional component / technical component indicator of 3 and is not separately payable when provided in 
the hospital setting. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services 
(99153) provided on April 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic colonoscopy provided on  
April 27, 2022. 
 
You asked the Plan to waive the deductible for a diagnostic colonoscopy. You say that you should not be 
responsible to pay this. 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 $750 deductible which applies to a diagnostic colonoscopy.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been 
met at the time a diagnostic colonoscopy was received on April 27, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for a diagnostic colonoscopy provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and accessories to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee cannot use the in-network provider. The 
Plan denied your request. The Plan says the requested provider is an OON provider and there is an in-network 
provider available where the enrollee can receive the services they need. 
 
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 
a pneumatic compressor and accessories to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you request that the Plan 
reconsider its denial of medical coverage and grant coverage for a portable oxygen concentrator that is truly 
portable. The Plan denied your request. The Plan says the Plan does not cover duplicate durable medical 
equipment such as oxygen device when the second item performs the same function as the one currently 
provided. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a portable oxygen gas and portable oxygen homefill system that was provided to 
you on May 20, 2022. The portable oxygen gas and portable oxygen homefill system serves the same purpose 
as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an injection of triamcinolone acetonide (a Medicare 
Part B prescription drug) provided on April 18, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you did not receive any injection at 
this office visit. The Plan denied your request. The Plan says that the cost-sharing amount you are being 
charged is correct. 
 
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. You say that you did not receive an injection at this visit. The Plan did not 
submit any supporting medical records showing that you received an injection of triamcinolone acetonide 
during this office visit. Without this information, the Plan has not supported the inclusion of this charge on this 
claim. Therefore, the Plan has not shown that its decision to ask you to pay this coinsurance amount is correct 
or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan 
has to waive the coinsurance for an injection of triamcinolone acetonide (a Medicare Part B prescription drug) 
provided on April 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be responsible to 
pay this. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an office visit. 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 copayment for an office visit provided on June 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on July 13, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
expecting such a high cost share responsibility 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 $295 
copayment for CT scans. 
 
You have been asked to pay a $295 copayment for a computed tomography (CT) scan. This item/service falls 
within the CT scans 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 computed 
tomography (CT) scan provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for pulmonary diagnostic services provided 
on March 2, 2021, and June 8, 2021. 
 
You asked the Plan to waive the copayments for pulmonary diagnostic services. You say that you would like to 
appeal your share of the cost because the services were crucial to your treatment plan. 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 up to a 
$50 copayment for each out-of-network Medicare-covered outpatient diagnostic procedure and test in an office 
setting or imaging center and up to a $175 copay for each Medicare-covered outpatient diagnostic procedure 
and test in an outpatient facility.  
 
 
  You have been asked to pay a total of $93.74 for pulmonary diagnostic services. The total includes a $50 
copayment for one pulmonary test and a $43.74 copayment for the second pulmonary test. 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 copayments for pulmonary diagnostic services provided on March 2, 2021, 
and June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient rehabilitation as the 
best continuum of care. The Plan denied your request. The Plan says the medical records do not show that the 
enrollee has any medical condition that requires a physician to see him at least three days a week. Skilled 
nursing or at an outpatient therapy center would be more appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted to an acute hospital on October 9, 2022, after a fall 
hitting his head. The enrollee sustained a subarachnoid hemorrhage in the left cerebellar hemisphere, a C-spine 
odontoid fracture, and a right distal radius fracture. The enrollee had no focal neuro deficits and is medically 
stable with debility. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim to be 
reconsidered due to COVID-19 issues. The Plan denied your request. The Plan says you did not timely file this 
claim. 
 
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 ambulance services was not filed until July 5, 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 ambulance services provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 6, 2020. 
 
You asked the Plan to pay for the lab services. You say that Medicaid originally paid the claim and then 
recouped it. The Plan denied your request. The Plan says you did not timely file this claim. 
 
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 lab services was not filed until May 17, 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 lab services provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (code 99203), the x-ray of the spine (code 
72100), and electrical stimulation (code 97014) provided on April 18, 2022, and the electrical stimulation (code 
97014) you received on May 2, 2022, from a chiropractor. 
 
You asked the Plan to pay for the chiropractic services. You say that you needed these chiropractic services and 
they allow you to keep your mobility. The Plan denied your request. The Plan says these services are not 
covered.  The Plan says it has covered the manual manipulation of the spine services (code 98941) you 
received on April 18, 2022, and May 2, 2022, minus your applicable copayment. It does not appear that you are 
appealing this copayment. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (code 99203), the x-ray of the spine (code 72100), and 
electrical stimulation (code 97014) provided on April 18, 2022, and the electrical stimulation (code 97014) you 
received on May 2, 2022, from a chiropractor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient surgery on March 22, 2022. 
 
You asked the Plan to waive the cost sharing for outpatient surgery. 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 $395 
copayment after your $1,000 plan deductible, for each Medicare-covered outpatient surgery at an outpatient 
hospital facility. Covered services include but are not limited to services in an emergency department or 
outpatient clinic, such as observation services or outpatient surgery. $810.19 deductible + $275.79 = $1,085.98. 
Therefore, reuslts in the total cost sharing amount of $1,085.  You have been asked to pay a $810.19 deductible and a $275.79 copayment for outpatient surgery. This 
item/service falls within the Outpatient hospital services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost sharing for outpatient surgery on March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73502 billed for date of service April 28, 
2022. 
  You asked the Plan to pay for procedure code 73502. You say that procedure code 73502 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says payment for 
code 73502 is bundled into payment for code 73522. 
 
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 73502 
is a column II code to column I code 73522. 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 73502 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services (11721) provided on April 4, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 debridement services (11721) provided on April 4, 
2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health on March 07, 
2022, to June 27, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient mental health. You say that you want to know why 
you are responsible for 40% coinsurance and not a $25 copay instead. 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 40% 
coinsurance of the total cost for each Medicare-covered mental health service. Covered services include Mental 
health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, 
clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care 
professional as allowed under applicable state laws. On March 07, 2022, the provider billed in the amount of 
$240 and the allowed amount is $128.05. $128.05 x 40% = $51.22. On April 4, 2022, and June 27, 2022, the 
provider billed in the amount of $175 and the allowed amount is $96.18. $96.18 x 40% = $38.47. $51.22 + 
$38.47 + $38.47 = $128.16. Therefore, results in the total cost sharing amount of $128.16. 
 
You have been asked to pay a 40% coinsurance for outpatient mental health. This item/service falls within the 
Outpatient mental health 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 outpatient 
mental health on March 07, 2022, to June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement grafts (D4263) for tooth #2, #14, 
#21, and #30. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee is feeling discomfort and needs 
these dental procedures done. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because bone replacement grafts are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement grafts (D4263) for tooth #2, #14, #21, and #30.