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

 
We decided that the Plan does not have to pay for ambulance services, advanced life support (ALS), emergency 
transport (A0427-QL) billed for date of service, January 7, 2022. 
 
You asked the Plan to pay for ambulance services billed at the ALS rate. You say that this claim was denied in 
error. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that for ambulance services, in a 
case where the time of death pronouncement was made before dispatch, no payment is made. In a case where 
the time of death pronouncement is after dispatch but before the beneficiary is loaded onboard the ambulance 
(before or after arrival at the point of pickup), the provider's/suppliers Basic Life Support (BLS) base is paid 
(no mileage or rural adjustment). The QL modifier must be used when submitting the claim. 
 
We find that code A0427-QL is not supported in the medical record. Specifically, A0427 is the ALS rate for 
emergency ambulance transportation rather than the BLS rate. Based on this information, we decided that 
Medicare rules for billing ambulance services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services, advanced life support (ALS), emergency transport (A0427-QL) billed for 
date of service, January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program.  You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status. You can receive further services at a lower level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 27, 2021, to November 
17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 psychotherapy provided on October 27, 2021, to 
November 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the $40 copayment for a specialist visit on January 5, 2022. 
 
You asked the Plan to reduce the $40 copayment for a specialist visit. You say that you should only be 
responsible for a $30 copayment. The Plan denied your request. The Plan says that you are responsible to pay a 
$40 copayment for a podiatrist visit. 
 
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 enrollees must pay a $30 copayment for Physician/Practitioner Services, 
Including Doctor's Office Visits.  
 
The Plan says you must pay a $40 copayment for a podiatrist visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $30 copayment for services obtained from a specialist, including 
consultation, diagnosis, and treatment by a specialist. Therefore, we decided that the Plan has to reduce the $40 
copayment for a specialist visit on January 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CX Bladder Detect test (0012M) provided January 12, 2022. 
 
You asked the Plan to pay for CX Bladder Detect test. You say that you disagree with this decision and 
appreciate prompt review of this information and authorization of coverage for the CX Bladder Detect test. The 
Plan denied your request. The Plan says the CX Bladder panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CX Bladder Detect test have not been met. Therefore, we decided that the Plan does not have to 
pay for CX Bladder Detect test (0012M) provided January 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on August 4, 
2021. 
 
You asked the Plan to pay for paramedic intercept services. You say that you would like this claim re-
processed. The Plan denied your request. The Plan says this claim was not billed appropriately by Medicare 
standards. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that items and services 
that are not medically necessary are not covered. Medicare rules state that the GY modifier indicates an item or 
service that is statutorily excluded or does not meet the definition of a Medicare benefit. 
 
The paramedic intercept services (A0432-SH-GY) billed for date of service August 4, 2021, were billed with 
the GY modifier. Based on this information, we decided that Medicare rules for coverage of paramedic 
intercept services have not been met. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services (A0432) provided on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
25, 2021, to August 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee had to be admitted 
to a different hospital and should not have another copayment. The Plan denied your request. The Plan says the 
enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $275 per day for days 1-6 and $0 per day after day 6 for each inpatient stay.  
 
The file shows that the enrollee was in the hospital from July 25, 2021, to August 5, 2021. Therefore, the 
enrollee has been asked to pay $275 per day for the first 6 days of inpatient care. The total for the stay is $1,650 
($275 copayment x 6 days = $1,650). The inpatient care falls within the Inpatient Hospital 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 copayment for inpatient hospital care provided 
from July 25, 2021, to August 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health visit provided on March 4, 
2020. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that you were not charged for 
this provider before. You say that they should be billed as PCP visits. 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 $30 
copayment for each therapy visit.  
 The file shows that the Plan verified with the provider that the visit was for behavioral health. Therefore, you 
have been asked to pay a $30 copayment for the mental health visit. The mental health visit 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 copayment for a 
mental health visit provided on March 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 4 at-home coronavirus test kits purchased on 
January 18, 2022. 
 
You asked the Plan to reimburse you for the coronavirus test kits. You say that you were advised that you can 
be reimbursed for these. You also say that you were not aware that there are certain dates from where we would 
apply the benefit. The Plan denied your request. The Plan says the at-home test kits were purchased before the 
benefit went into effect on February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the coronavirus test kits have not been met. Specifically, the tests were purchased prior to the 
effective benefit date. The record also shows that you were not given misinformation by the plan representative 
as you did not call them until February 10, 2022. Therefore, we decided that the Plan does not have to 
reimburse you for the 4 at-home coronavirus test kits purchased on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
4, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment applied was correct. You saw 
a specialist provider. 
 
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 $50 
copayment for in-network physician/practitioner services.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the In-Network Physician/Practitioner Services, Including Doctor's 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 a specialist office visit provided on March 4, 2022.  
 Your complaint about the code change, or this visit being needed because of covid, is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home coronavirus test kit purchased on January 4, 
2022. 
 
You asked the Plan to pay for the at-home coronavirus test kit. You say that you purchased at-home tests to 
check your coronavirus status. You also say that you do not have proof of purchase, only proof of payment. 
The Plan denied your request. The Plan says that the at-home test kit was purchased prior to the benefits 
effective coverage date. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home coronavirus test kit have not been met. Therefore, we decided that the Plan does not 
have to pay for the at-home coronavirus test kit purchased on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 7, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you already paid $350 
copayment and dont know why you owe anymore. 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 $325 
copayment for each Medicare covered ambulatory surgical center visit.  
 
You have been asked to pay $325 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 April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement. However, 
the documentation does not support that the enrollee would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status. The enrollee can receive further services at a lower level of 
care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. 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 an x-ray provided on 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has age-related osteoporosis without osteoporotic fracture. The requested medication is a new 
start. The Plan requires a trial of zoledronic acid before they will approve the requested drug. The provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternative. The record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's 
preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
August 5, 2021, to August 11, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this stay should be 
covered. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $275 copayment per day for days 1 through 6.  
 
 
 
 
 
 The enrollee has been asked to pay $1,650 ($275 x 6 days) copayment for inpatient hospital stay. Inpatient 
hospital stay falls within the Inpatient Hospital 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 copayment for inpatient hospital stay provided from August 5, 2021, to August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you were told by the hospital and a 
Plan representative that this provider was in-network. The Plan denied your request. The Plan says this was 
denied for no 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 a hospital outpatient clinic visit provided on 
February 16, 2022, by an out-of-network (OON) provider.