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

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that it is necessary for you to 
receive more routine transportation. The Plan denied your request. The Plan says the benefit for routine 
transportation has been exhausted. 
 
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 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 24 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vacuum erection system (L7900). 
 
You asked the Plan to pre-approve the vacuum erection system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
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 the vacuum erection system (L7900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that a repeat procedure is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that that a repeat epidural steroid injection (ESI) 
when the first injection directly and significantly provided improvement of the condition being treated may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months 
 
We looked at the file and Medicare rules. In this case, the documentation indicates that the requested repeat 
epidural steroid injection was performed less than 3 months before the requested repeat epidural steroid 
injection. Based on this information, we decided that Medicare rules for coverage of a repeat epidural steroid 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural 
steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on December 16, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to appeal the denial of the 
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 Laboratory services provided on December 16, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 6, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 home health visit provided on November 6, 
2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health hospital stay 
provided from August 6, 2021, to August 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient mental health hospital stay. You say that your 
father was approved and enrolled in a Medical Financial Assistance (MFA) program. 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 per day for days 1-7 for a mental health hospital stay for San Diego County plan members. The 
contract also says that you pay $0 for the remainder of the covered hospital stay after day 7. The record shows that the enrollee was not enrolled in the MFA program during the hospital stay from August 
6, 2021, to August 17, 2021. The enrollee has been asked to pay a total of $1,575, which is a $225 copayment 
per day for days 1-7 for an inpatient mental health hospital stay ($225 copayment x 7 days = $1,575). An 
inpatient mental health hospital stay falls within the Inpatient 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 an inpatient mental health hospital stay provided from August 6, 
2021, to August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left prosthetic leg to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve left prosthetic leg. 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 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 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 
left prosthetic leg to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428-
HN, A0425-HN) provided on July 21, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that these services were necessary, and this 
claim is not a duplicate. The Plan denied your request. The Plan says this claim is a duplicate of another claim 
that has already been processed. 
 
While we did find documentation to support that this claim was previously submitted to the Plan, this 
documentation also shows that the initial submission of this claim was not paid and was denied due to a lack of 
prior authorization. Therefore, this claim is not a duplicate, but a request for payment on a previously denied 
claim. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance transport. Our reviewer says 
that the ambulance transport from the hospital to the nursing facility was not medically necessary in this case. 
Our physician reviewer found that the enrollee had a headache one day following hitting her head getting into 
wheelchair van. She was transported via ambulance to the hospital. She used a wheelchair at the nursing home. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were 
contraindicated for this enrollee on July 21, 2021. She was able to safely sit in wheelchair. The documentation 
did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that 
only a fully-equipped ambulance can provide for safe transport on July 21, 2021. Treatment during transport 
was not needed. The enrollee required head imaging which was be completed at the hospital. Therefore, the 
documentation does not support that transport via ambulance was medically reasonable and necessary for the 
enrollee on the date in question. 
 
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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergent ambulance transportation services (A0428-HN, A0425-HN) 
provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry provided 
on December 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for mass spectrometry and tandem mass spectrometry. You say that most in-network 
providers cannot perform such complex, detailed, drug testing services. You also say that the referring 
physician is a contracted provider and has received reimbursement for his or her services. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan, and the services were not referred 
by a network provider or rendered in an in-network facility. The Plan also says that they have also determined 
that these services are not urgent or emergent, nor were they approved in advance. 
 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 mass spectrometry and tandem mass spectrometry 
provided on December 31, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on August 3, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you met your maximum out-of-pocket on 
July 13, 2021. 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 $250 
copayment for diagnostic radiology services, including MRIs. The Plan contract also says that enrollees must 
pay a $3,450 maximum out-of-pocket (MOOP) per calendar year. 
 
The record shows you had not met your MOOP at the time this claim was processed. You have been asked to 
pay a $250 copayment for an MRI. An MRI 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 magnetic 
resonance imaging (MRI) of the lumbar spine provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you have seen the OON provider 
prior to being enrolled into the Plan and you would like to see them again. The Plan denied your request. The 
Plan says a list with multiple in-network provider that are accepting new patients and provide the same quality 
of service that are all within the approved distance from the enrollees residence was given to the enrollee. 
 
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 specialist office visit to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the outpatient surgery. You say that you would like to see the OON provider 
because of his specialty. The Plan denied your request. The Plan says they have approved the surgery with an 
in-network provider and the enrollee has agreed and already scheduled the surgery with the in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient surgery to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 11, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are asking for an explanation 
as to why the balances were not covered under the insurance plan. The Plan denied your request. The Plan says 
you have been charged the correct copayment 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 $125 
in-network copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed 
in a physician's office or free-standing facility.  
 You have been asked to pay $107.29, which is less than the standard $125 copayment for an ultrasound. An 
ultrasound 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 an ultrasound provided on October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the PT visits provided on December 2, 
2021, and December 17, 2021. 
 
You asked the Plan to waive the copayment for PT visits. You say that you believe the copayments were 
applied incorrectly. The Plan denied your request. The Plan says the copayments were applied 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 Medicare-covered physical, occupational and speech therapy visits.  
 
You have been asked to pay a total of $70 ($35 copayment x 2 visits = $70) for PT visits. PT visits falls within 
the Outpatient rehabilitation 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 PT visits provided on December 2, 2021, and December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on November 15, 
2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the scan should be covered under 
Medicare. The Plan denied your request. The Plan says the copayment was applied 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic) for the CT scan. 
 
 You have been asked to pay $160 for the CT scan. A CT scan falls within the Other outpatient diagnostic tests 
- Radiological diagnostic services, not including x-rays 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 the CT scan provided on November 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on August 4, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that your out-of-pocket maximum was met 
before this visit. The Plan denied your request. The Plan says copayment 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 $25 
copayment for each individual or group therapy visit for Medicare-covered outpatient mental health services.  
 
You have been asked to pay $25 copayment for the office visit. The office visit falls within the Outpatient 
mental health care benefit category. The records show your maximus out-of-pocket was not met until after this 
claim was processed. 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 office visit on August 4, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. You are functioning below your baseline. Daily skilled 
services are required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.