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 with no transport 
(A0998) provided on October 3, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
situation you were in could have been fatal if you did not seek help. The Plan denied your request. The Plan 
says the ambulance was called, and you were not transported to an emergency facility. The Medicare 
ambulance benefit is a transport benefit. The Plan also says that if no transport of a Medicare beneficiary 
occurs, then there is no Medicare covered service. 
 
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 October 3, 2021. 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 response and treatment with no 
transport (A0998) provided on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on November 15, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the eye exam. You say that the providers rely on facility staff to verify eligibility 
and obtain authorization from the patients insurance company. The Plan denied your request. The Plan says 
the services were provided out-of-network and were not 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 the eye exam provided on November 15, 2021, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal and replacement of a loop recorder for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee has had a loop recorder since 2017 to monitor her 
atrial fibrillation that has not shown significant events that have prompted any further management changes. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The implantable loop 
recorder (ILR) is being requested to allow continued monitoring of the patients atrial fibrillation. As such, 
based on current guidelines and the documentation provided, there is insufficient clinical evidence to support 
the medical appropriateness and necessity of replacing the patients old ILR with a new ILR. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal and replacement of a loop recorder for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Acupuncture treatment on July 9, 2021 to 
September 2, 2021. 
 
You asked the Plan to waive the copayment for Acupuncture treatment. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the copayment applied was 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 $40 
copayment for each specialist's office visit for Acupuncture treatment.  
 
You have been asked to pay a $40 copayment for each specialist's office visit for Acupuncture treatment. 
Acupuncture treatment falls within the Acupuncture (Medicare-covered) for chronic low back pain 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 Acupuncture treatment on July 9, 2021 to 
September 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on October 21, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this service should be reprocessed and paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the continuation of hyperbaric oxygen therapy. You say that this treatment 
continues to be medically reasonable and necessary. The Plan denied your request. The Plan says the criteria 
for coverage of hyperbaric oxygen therapy no longer is medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen (HBO) therapy is covered as 
adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with 
standard wound therapy and must be used in addition to standard wound care 
 
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 continuation of hyperbaric oxygen 
therapy.  Our reviewer says that the continuation of hyperbaric oxygen therapy is not medically reasonable and 
necessary. Our physician reviewer found this patient has severe peripheral vascular disease and gangrene of the 
2nd toe of the L foot.  HBO treatment was started on February 16, 2022. The note from March 2, 2022, 
indicates no improvement, and toe amputation was apparently done some time between March 2 and March 7.  
A nurse's message to the patient on March 7 indicates HBO will be stopped for a week and then maybe 
restarted. There is no indication that the amputation wound is not healing. Because the infected bone and tissue 
have been removed, there is no longer an indication for HBO. The denial is upheld. 
 
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 continuation of hyperbaric oxygen therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of hyperbaric oxygen therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 24, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code 
remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat and a bath/shower chair. 
 
You asked the Plan to pre-approve the items. You say that these are medically necessary. The Plan denied your 
request. The Plan says these items are not medical in nature and are not medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do 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 a raised toilet seat and a bath/shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of April 30, 
2022. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing this denial. The 
Plan denied your request. The Plan says continued inpatient psychiatric care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
  
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of April 30, 
2022. Our physician reviewer found it is not expected that the enrollee would improve in a reasonable period of 
time beyond the date in question as the enrollee does not have suicidal or homicidal ideation noted and had no 
auditory or visual hallucinations. The enrollee did not show any abnormal behaviors or symptoms which would 
require additional acute treatment. It does not appear medically reasonable and necessary to have psychiatric 
care provided at the acute inpatient hospital level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive care management services for a single high-
risk disease (G2064) provided on November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for comprehensive care management services for a single high-risk disease. You say 
that the claim is denied as out-of-network, and prior authorization will be required. You also say that you do 
not have prior authorization. The Plan denied your request. The Plan says this provider is out-of-network with 
the Plan, and authorization was not obtained prior to the services being 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 comprehensive care management services for a 
single high-risk disease (G2064) provided on November 16, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 5, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full upper respiratory panel coded as 87486, 87496, 87498, 
87502, 87532, 87541, 87581, 87640, 87651 provided September 23, 2021. 
 
You asked the Plan to pay for the full upper respiratory panel. You say that due to the critical clinical value of 
the testing that benefits the enrollee, you ask for reconsideration of the denial and request payment in full for 
the testing. The Plan denied your request. The Plan says the services does not meet Medicare's reasonable and 
necessary criteria. 
 
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 pay for the full upper respiratory panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found reimbursement is usually allowed for multiplex PCR-based panel testing of up to 
5 respiratory pathogens for patients displaying signs and symptoms of a respiratory tract infection, as 
evidenced by a compatible clinical syndrome including at least one of the following: temperature of 102 or 
greater, pronounced dyspnea, tachypnea, or tachycardia. There was no specific clinical rationale for the 
requested full upper respiratory panel coded as 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 
87651. The review has determined that the items/services at issue in this case are not medically reasonable or 
necessary. 
 
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 full upper respiratory panel have not been met. Therefore, we decided that 
the Plan does not have to pay for full upper respiratory panel coded as 87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87640, 87651 provided September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on December 3, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior 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 the telehealth 
services provided on December 3, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day management services (99239) provided on 
December 23, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration because this provider is enrolled in Medicare. The Plan denied your request. The Plan says that 
the provider is non-participating and is not eligible for enrollment with Medicare. 
 
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. Specifically, the documentation clearly shows that the provider in this case is 
enrolled in Medicare. The Plan has not forwarded any evidence to support why this provider is not eligible for 
payment. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for hospital discharge day management services (99239) provided on December 23, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses (S0500) purchased on 
December 6, 2020. 
 You asked the Plan to pay for disposable contacts. You say that these services were not coded correctly before, 
and you would like reimbursement for the disposable contacts. The Plan denied your request. The Plan says 
you received new eyeglass lenses on September 21, 2020, which used your full eye wear benefit at that time. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 per year. 
 
We looked at the file and the Plan's rules. The documentation shows that you used the full $200 annual 
allowance on your purchase of eyeglass lenses in September of 2020. Based on this information, we decided 
that the Plan's rules for coverage of disposable contacts have not been met. Therefore, we decided that the Plan 
does not have to pay for the disposable contact lenses (S0500) purchased on December 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on July 28, 2021. 
 
You asked the Plan to pay for these services. You say that the technician assured you the vaccine would be 
covered. The Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
 
 
 
  
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on July 28, 2021.