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

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you did not request 
the ambulance ride to transport you from one facility to another and was not aware one was called until it had 
already arrived. You say that this was not an emergency and could have found a ride. 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 a $225 
copayment for each Medicare-covered service or one-way trip by ground transportation.  
 
 
  You have been asked to pay a $225 copayment for an ambulance transportation. An 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 
an ambulance transportation provided on March 18, 2022.  
 
Your complaint about you not requesting the ambulance 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on December 15, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records clearly show medical 
necessity. The Plan denied your request. The Plan says the code remains not supported. 
 
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, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that 
the sedation services required the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the moderate sedation services provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmological office visit provided on March 21, 
2022, by an OON provider. 
 
You asked the Plan to pay for an ophthalmological office visit. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 ophthalmological office visit provided on 
March 21, 2022, by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a pathology procedure provided on March 2, 2022. 
 
You asked the Plan to pay for a pathology procedure. You say that the service provided was medically 
necessary. The Plan denied your request. The Plan says that screening services without a valid medical 
diagnosis related to the health of the enrollee are not a benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for a pathology procedure by an in-network contract provider. The file does not show 
that the plan provided a notice of non-coverage. Under Medicare rules, this means the pathology procedure 
considered is approved by the plan. Therefore, we decided that the Plan has to pay for the pathology procedure 
provided on March 2, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the rotary wing air mileage (A0436) and rotary wing air transport 
(A0431) provided on March 26, 2022. 
 
You asked the Plan to pay for the rotary wing air mileage and air transport. The Plan denied your request. The 
Plan says that at the time of the transfer the enrollee's vital signs were stable and they had no respiratory 
insufficiency or impending respiratory failure. 
 
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. The Plan did not provide any medical records for this case. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or 
that the transport was not medically necessary. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pay for the rotary wing air mileage (A0436) 
and rotary wing air transport (A0431) provided on March 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit on December 4, 
2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share has been 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 $45 for 
each covered visit or consultation in an outpatient location with a specialist.  
 You have been asked to pay $45 for a specialist office visit. A specialist office visit 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 a specialist office visit on December 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee requires regular 
oncologist visits, and you are requesting additional trips for their transportation. The Plan denied your request. 
The Plan says according to the enrollee's trip report, the enrollee has used 49 trips. The Plan also says the 
enrollee has zero trips remaining and has exceeded the 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 up to 48 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 additional routine transportation.
Appeal type: Supplemental Benefit
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 trips. You say that you need additional trips. The Plan denied 
your request. The Plan says additional trips beyond the 60 approved per calendar year are not covered. 
 
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 60 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 a bar for back support. 
 
You asked the Plan to pre-approve the requested item. You say that the bar supports your back. The Plan 
denied your request. The Plan says the item is mostly for convenience purposes. 
 
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 would be 
helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-
approve a bar for back support.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that the enrollee needs the equipment to 
make her daily life better. The Plan denied your request. The Plan says Medicare excludes separate coverage of 
this item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that the requested wheelchair is being requested for use in a SNF. Therefore, we decided that 
the Plan does not have to pre-approve an ultra-lightweight wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the stent placement provided on January 
27, 2022, to January 31, 2022. 
 
You asked the Plan to reduce the coinsurance for the stent placement. You say that you were only charged 
$285 for the same procedure the previous year. 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 20% 
coinsurance for Diagnostic Procedures/Tests. 
 
You have been asked to pay 20% coinsurance for the stent placement. This item/service falls within the 
Diagnostic Procedures/Tests 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. The allowed amount for the stent placement is $9,171.50. Your 20% coinsurance of this 
amount is $1,834.30. Therefore, we decided that the Plan does not have to reduce the coinsurance for the stent 
placement provided on January 27, 2022, to January 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits 
 
You asked the Plan to pre-approve ten additional physical therapy visits. The Plan denied your request. The 
Plan says the request does not meet the criteria outlined in the Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 ten additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found your medical history is significant for 
malaise, fatigue, anxiety, hypertension, vertigo, hypothyroidism, depression, and difficulty walking. On review 
of the available records you do not meet the Medicare coverage criteria for the requested additional therapy 
visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ten additional physical therapy visits
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 11, 
2021. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 procedure code. 
 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets full criteria for LTAC 
admission. The Plan denied your request. The Plan says after an internal medical review it was determined that 
based on Medicare guidelines, the long term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with unstable angina and 
congestive heart failure requiring coronary artery bypass graft surgery times 3, complicated by acute 
respiratory failure and a cerebrovascular accident. The enrollee was treated with prolonged intubation, tube 
feeds, percutaneous endoscopic gastrostomy placement and trach placement. Recent notes describe the enrollee 
as responding to treatment and now able to sit up in a chair, tolerating T-piece on 10L/m on oxygen support, 
and tolerating tube feeds.  The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on 
February 8, 2022. 
 
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that you should not be 
responsible to pay this because it was an abdominal aortic aneurysm screening. The Plan denied your request. 
The Plan says the cost share has been 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 $100 per 
day for a Medicare-covered ultrasound.  
 
You have been asked to pay $100 for an abdominal ultrasound. An abdominal 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 abdominal ultrasound provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for telehealth visits on January 5, 2022, and 
January 25, 2022. 
 
You asked the Plan to waive the copayments for telehealth visits. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says the cost share has been 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 $45 for 
each covered telehealth visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay $90 for telehealth visits. Telehealth visits fall 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 copayments 
for telehealth visits on January 5, 2022, and January 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided February 10, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not want an ambulance and do not 
feel you should be billed for the service. The Plan denied your request. The Plan says this service is not 
covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on February 10, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient office visit (99215) and noninvasive ear or 
pulse oximetry for oxygen saturation (94760) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit and noninvasive ear or pulse oximetry. You say 
that you have been seeing the requested doctor since 2018. The Plan denied your request. The Plan says the 
provider you are requesting to be treated by is not contracted with the Plan. The Plan also says your obstructive 
sleep apnea (OSA) is now stabilized and care can be safely assumed by an 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 
an outpatient office visit (99215) and noninvasive ear or pulse oximetry for oxygen saturation (94760) to be 
provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on January 17, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from January 
5, 2022, to January 16, 2022. The Plan says, per Medicare guidelines, the provider must bill Original Medicare 
for the services rendered on January 17, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on January 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on January 17, 2022.