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

 
We decided that the Plan has to pay for the ambulance service (A0999) and ground mileage (A0425) provided 
on January 21, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you feel you should not 
be at fault for the paramedic from one ambulance company in a different ambulance. The Plan denied your 
request. The Plan says that you lived a short distance from the hospital and required emergency transport to the 
hospital, but there was no indication for advanced life support treatment of your acute stroke. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. 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 service and ground mileage. 
Our reviewer says that the ambulance transportation on January 21, 2022 was medically necessary. Our 
physician reviewer found your presenting symptoms did meet prudent layperson criteria for emergency care. 
Our reviewer also found that you had sudden aphasia, right sided weakness, and were unable to communicate. 
 
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 service and ground mileage have been met. Therefore, we 
decided that the Plan has to pay for the ambulance service (A0999) and ground mileage (A0425) provided on 
January 21, 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: Unfavorable

 
We decided that the Plan does not have to waive the cost share for dental code D2740 provided on December 7, 
2021. 
 
You asked the Plan to waive the cost share for dental code D2740. You say that you feel you should not have to 
pay this cost share amount and you would like the Plan to reconsider your request. The Plan denied your 
request. The Plan says you received a porcelain/ceramic crown (D2740) on the date of service at issue in this 
appeal. The Plan says the correct cost share has applied per your contract with the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
We looked at the file and the Plan's contract. The Plan's contract says enrollees must pay a $50 deductible per 
year for dental services and a 50% coinsurance for porcelain/ceramic crowns with dental code D2740. The file 
shows that the Plan applied a $50 deductible and a 50% coinsurance for dental code D2740 correctly. 
Therefore, we decided that the Plan does not have to waive the cost share for dental code D2740 provided on 
December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays rendered on August 10, 2021. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the x-rays rendered on August 
10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation is covered when specific 
criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain. The 
records do not contain radiological evidence of knee osteoarthritis for this enrollee. The criteria for coverage 
are not met and the Gelsyn-3 is not reasonable or medically necessary at this time. 
 
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 Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 5, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing with supporting medical records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and authorization was not 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 provided on November 5, 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 an office visit provided on December 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-
network with the Plan and authorization was not 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 provided on December 21, 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 laboratory services provided on January 2, 2022 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 laboratory services provided on January 2, 
2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on November 15, 
2021. 
 
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 was not reported correctly. 
 
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 74230: 
 
Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck 
radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study 
 
CPT 74240: 
 Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed 
image(s), when performed; single-contrast (eg, barium) study 
 
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 these services were provided in a 
nursing home, and therefore are an exclusion. 
 
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 radiology services provided to the enrollee on November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B Drugs provided on 
September 24, 2020, October 2, 2020, and October 9, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B Drugs. You say that you don't think you are 
responsible for these charges. The Plan denied your request. The Plan says the coinsurance 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 20% of 
the cost for Part B covered drugs.  
 
 
  You have been asked to pay a total of $283.64 for Part B Drugs.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
September 24, 2020 Injection $11.08 20% $2.22 
September 24, 2020 Injection $55.40 20% $11.08 
September 24, 2020 Infusion Supplies $365.20 20% $73.04 
October 2, 2020 Injection $5.54 20% $1.11 
October 2, 2020 Injection $55.40 20% $11.08 
October 2, 2020 Infusion Supplies $319.55 20% $63.91 
October 9, 2020 Injection $11.08 20% $2.22 
October 9, 2020 Injection $55.40 20% $11.08 
October 9, 2020 Injection $174.30 20% $34.86 
October 9, 2020 Infusion Supplies $365.20 20% $73.04 
Total    $283.64 
 
Medicare Part B Drugs falls within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B Drugs provided on September 24, 2020, October 2, 
2020, and October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (CPT code E1392). 
 You asked the Plan to pre-approve the portable oxygen concentrator. You say that you need the portable device 
because the tanks are too heavy, and you get winded when you carry them. You state you need something so 
that you can be more mobile. The Plan denied your request. The Plan says Medicare does not cover duplicate 
or redundant durable medical equipment such as oxygen device when the second item performs the same 
function as the one currently provided to you. The Plan states there is no medical documentation to support 
your need for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable oxygen concentrator have not been met. The equipment provided to you continues to 
adequately meet your medical need. Therefore, we decided that the Plan does not have to pre-approve the 
portable oxygen concentrator (CPT code E1392).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you are required to 
have colonoscopies every 3 years for preventative measures due to your history of polyps. 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 $350 
copayment for each Medicare-covered outpatient surgical service.  
 
 
  You have been asked to pay $350 for outpatient surgery services. Outpatient surgery services fall within the 
Outpatient hospital 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 outpatient 
surgery services provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 genetic testing provided on September 10, 
2021. 
 
You asked the Plan to pay for the Guardant360 genetic testing. You say that the POS rules being cited do not 
apply to lab tests paid on the Clinical Laboratory Fee Schedule. The Plan denied your request. The Plan says 
the POS code reported does not match the location where the sample was taken as required. 
 
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 Guardant360 genetic testing 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 the Guardant360 genetic testing provided on September 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network 
(OON) provider on December 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on  
December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
January 25, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that the ECG was part of your annual 
wellness visit and you should not have a copayment. 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 no 
coinsurance, copayment, or deductible for the annual wellness visit. 
 
Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and 
tests, including ECG's. The file shows that you were not charged for the wellness visit. However, the ECG is an additional service that 
goes beyond the scope of a wellness visit. Therefore, you have been asked to pay $14.80, which is less than the 
$75 copayment for the ECG. The ECG 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 electrocardiogram 
(ECG) provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 16, 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 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 an office visit provided on February 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that authorization is not required for this service. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and authorization was not 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 
provided on February 22, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomography (SPECT) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that SPECT may not be used following an inconclusive fluorodeoxyglucose (FDG)-
positron emission tomography (PET) performed to evaluate myocardial viability. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
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 scan. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has had prior myocardial infarction, and is now noted to have atrial fibrillation and low 
voltage on electrocardiogram. SPECT has been requested to evaluate myocardial viability and possible 
amyloid. The need for myocardial viability assessment is a recognized and viable test to evaluate the 
myocardium for viability and should be approved even without a prior positron emission tomography (PET) 
scan. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a single photon emission computed tomography (SPECT) scan.   
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on November 19, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the GeneSight testing rendered on November 19, 2021.