Persius/hicric huggingface dataset:
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 January 6, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you needed treatment for low blood sugar 
which was stabilized by the ambulance crew. 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 January 6, 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 January 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 home health physical therapy visits. 
 
You asked the Plan to pre-approve 16 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 16 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 16 home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator (64561). 
 
You asked the Plan to pre-approve a sacral nerve stimulator (64561). You say that the requested sacral nerve 
stimulator (64561) is medically necessary. The Plan denied your request. The Plan says the requested sacral 
nerve stimulator (64561) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a sacral nerve stimulator (64561). Our 
reviewer says that the requested sacral nerve stimulator (64561) is not medically necessary. Our physician 
reviewer found the records do not demonstrate that the enrollee has adequate ability to record voiding diary 
data such that clinical results of the implant procedure can be properly evaluated. Also, the records show that 
the enrollee has an underlying neurological condition contributing to his fecal and urinary incontinence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacral nerve stimulator (64561) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sacral nerve stimulator (64561).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for phlebotomy, therapeutic services provided on April 
27, 2022. 
 
You asked the Plan to waive the copayment for phlebotomy, therapeutic services. You say that you should not 
have a copayment as you have had these services for months and never had to pay a copayment. The Plan 
denied your request. The Plan says that the services are approved for coverage. 
 
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 has not documented if a copayment was appropriated applied and the 
rule to support the case. Therefore, we decided that the Plan has to waive the copayment for phlebotomy, 
therapeutic services provided on April 27, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intra-fraction localization and motion tracking during 
delivery of radiation therapy (G6017) provided on April 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for intra-fraction localization and motion tracking. You say that the services were 
performed and billed accordingly. You say the services should be reconsidered for payment The Plan denied 
your request. The Plan says no prior authorization was obtained for the services rendered. 
 
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 intra-fraction localization and motion tracking 
during delivery of radiation therapy (G6017) provided on April 28, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording); placement of transesophageal probe only provided to 
the enrollee on March 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code cannot be unbundled. 
 
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 93313 
is a column II code to column I code 93312 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only provided to the enrollee on 
March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on May 2, 2022, by an OON provider. 
 
You asked the Plan to pay for an x-ray. You say that although the provider is out-of-network for the member's 
Plan, the member cannot choose the radiologist who reads their report. 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 x-ray provided on May 2, 2022, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5267) purchased on 
April 22, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were not purchased from 
the Plans select hearing aid provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5267) purchased on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning provided on April 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for assessment of and care planning. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
  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 assessment of and care planning provided on April 
20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92014) provided on May 10, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the nursing home should have obtained 
authorization. The Plan denied your request. The Plan says this service is not covered because it was provided 
OON. 
 
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 the medical eye exam (92014) provided on May 
10, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 18, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you were experiencing dizziness and 
confusion due to low blood sugar. You were examined and found your blood sugar was climbing. There was no 
need to be transported to a hospital. The Plan denied your request. The Plan says the transport of a Medicare 
beneficiary must occur for an ambulance transport to be payable. 
 
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 April 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 an office visit provided on June 28, 2022, 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 visit (99348) for trimming of dystrophic nails 
(G0127) and nail debridement (11720) provided on April 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visit and nail treatments. You say that the enrollee told you that the 
services are covered by Medicare. You say that the enrollee misled you by providing incorrect insurance 
information and therefore, you were unable to obtain prior authorization. The Plan denied your request. The 
Plan says the claim was denied for failure to obtain a prior authorization. The Plan determined that the services 
provided to the enrollee were neither urgent nor emergent. The services also could have been rendered by in-
network providers. Additionally, the Plan says that despite the enrollee providing incorrect insurance details, it 
is the provider's responsibility to verify the enrollee's insurance at the time of service. 
 
 
 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 visit (99348) for trimming of dystrophic 
nails (G0127) and nail debridement (11720) provided on April 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported by the medical records submitted. 
 
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 the denied codes is: 
 
CPT 22585: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); each additional interspace (List separately in addition to code for primary procedure) 
 
CPT 22853: 
 
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation 
for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
 We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that the 
denied codes were actually rendered in this case. The enrollee underwent a posterior spinal fusion at levels T4-
S1; posterior segmental instrumentation of the spine levels T4-S1; pelvic fixation ICBG; osteotomy T9-S1; 
laminectomy T7-T9; ligament repair T3-T4 and insitu fusion; and spinal cord stimulator removal on 
3/22/22. However, detailed documentation is not evident regarding any anterior fusion procedures having been 
performed. The procedure report in detail indicates a posterior fusion and procedures having been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for provided on April 14, 2022. 
 
You asked the Plan to reduce the copayment for diagnostic test. You say that diagnostic echocardiograms are 
covered by Medicare at 80% and you should have a copayment of $34.40, not $120. 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 $120 
copayment for Medicare-covered radiological diagnostic service.  
 
You have been asked to pay $120 copayment for diagnostic test. This item/service falls within the Medicare-
covered radiological diagnostic service 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 reduce the copayment 
for provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and veinous ablation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and veinous ablation to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 consultation and veinous ablation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on January 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were rendered to the enrollee in good 
faith. You say that the rendering physician relies on office staff to verify the enrollee's eligibility and to obtain 
the proper authorization from the Plan. The Plan denied your request. The Plan says services rendered by out-
of-network providers are not covered unless a prior authorization is 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 an office visit (99213) provided on January 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist visit provided on April 25, 
2022. 
 
You asked the Plan to reduce the copayment for a specialist visit. You say that you were charged a $30 
copayment and should have only been $10. 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 $10 
copayment for physician/practitioner service. 
 
You have been asked to pay a $10 copayment for a specialist visit. This item/service falls within the 
physician/practitioner service 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 reduce the copayment for a specialist 
visit provided on April 25, 2022.