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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 8, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed to call 
the ambulance since you felt you were having a heart attack. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for round-trip ambulance services.  
 
You have been asked to pay a $300 copayment for the ambulance transportation. The 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 ambulance transportation provided on January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on August 18, 
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 the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. 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 physician 
services provided to the enrollee on August 18, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a COVID-19 rapid antigen test provided to the enrollee on November 
15, 2021. 
 
You asked the Plan to pay for the test. You say that the claim should be reviewed and processed. The Plan 
denied your request. The Plan says that the documentation only lists the test, but does not support that the test 
was performed. 
 
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 substantiated their denial in this case. The records show that a 
diagnosis of cough, contact with and (suspected) exposure to other viral communicable diseases, and contact 
with and (suspected) exposure to Covid-19. The records also show that a COVID-19 rapid antigen test was 
administered based on these diagnoses, along with an outpatient visit, and specimen handling, under "Services 
Performed." This is sufficient to indicate that the test was performed. Therefore, we decided that the Plan has to 
pay for a COVID-19 rapid antigen test provided to the enrollee on November 15, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87481, 87640, 87641, 87651, 87653, 
87591 and 87661) provided on March 1, 2022. 
 
You asked the Plan to pay for lab services. You say that these services are supported as billed. The Plan denied 
your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between each of the services at issue and 87801. These PTP edits each have a modifier indicator of 1, 
meaning modifiers associated with NCCI are allowed to bypass these edits. However, an appropriate modifier was not billed with any of these services. This claim was not billed appropriately by Medicare coding 
regulations. 
 
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 codes 
87798, 87481, 87640, 87641, 87651, 87653, 87591 and 87661 are all column II codes to column I code 87801. 
These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (87798, 87481, 87640, 87641, 87651, 87653, 87591 and 87661) provided on March 1, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on February 
26, 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 the appropriate payment for the claim is for a later episode timing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the denied home health services not supported in the medical record. Specifically, there was no 60 
day gap in home health services between the end of the prior period of care, and the start of this period of care. 
Therefore, the use of HIPPS code representing an early episode (1CB11) is not appropriate for this case. 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 home health services provided to the enrollee on February 26, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an ultrasound. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. 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 Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Neulasta Onpro as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta Onpro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on January 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you are requesting payment on the claim. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on January 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410) provided by a participating 
provider. 
 
You asked the Plan to pre-approve an apicoectomy. You say that these services are needed. The Plan denied 
your request. The Plan says the requested dental service is not covered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
apicoectomy (D3410) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) plastic surgeon. 
 
You asked the Plan to pre-approve an office visit. The Plan says the services have been requested out-of-
network. The Plan has recommended in-network providers available to provide this 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 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 office visit to be provided by an out-of-network (OON) plastic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are submitting documentation for review. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no referral 
from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 1, 
2020. 
 
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 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 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 drug testing services provided to the enrollee on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the folding, wheeled walker, adjustable or fixed height 
(E0143) provided on February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the walker. You say that you did not realize that you needed to ask about this 
before you went to get this. You needed this to get to the doctor and to stay in your house so you don't go into a 
nursing home. The Plan denied your request. The Plan says enrollees must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before 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 the folding, wheeled walker, adjustable or fixed 
height (E0143) provided on February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a cystourethroscopy provided to the enrollee on February 24, 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 that the cystourethroscopy was performed to aid in identification of the ureters intraoperatively 
at the start of the low anterior resection procedure, and a diagnosis representing this indication was not billed. 
 
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 52332 is "Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)." 
 
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 supported by the medical records. Our reviewer found that in this case, the enrollee has a 
diagnosis of rectal cancer and underwent low anterior resection. The procedure defined by CPT code 52332 
was performed in conjunction with that procedure. The plan is incorrect that the diagnosis is not consistent with 
the procedure.  The elements of the coverage criteria are satisfied. 
 
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 been met. Therefore, we decided that the Plan has to pay for a 
cystourethroscopy provided to the enrollee on February 24, 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 pre-approve arthrocentesis (20611) and a Synvisc injection (J7325). 
 
You asked the Plan to pre-approve arthrocentesis and a Synvisc injection. 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 follows Medicare rules. Medicare rules say that the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan 
(Hymovis). 
 
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 arthrocentesis and a Synvisc injection. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
not had an adequate trial of physical therapy. Therefore, the request is deemed not medically reasonable or 
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 arthrocentesis and a Synvisc injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve arthrocentesis (20611) and a Synvisc injection (J7325).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says that the services requested are not medically necessary and reasonable. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found Patient has multiple comorbidities stated in clinical documentation that would warrant close medical 
supervision on an inpatient basis focused on rehabilitation. Evaluating therapist recommend intense 
rehabilitation and patient requires multiple therapy disciplines (PT, OT). BKA is an IRF compliant diagnosis. 
Based on clinical documentation, patient is likely to significantly benefit and participate in an intensive 
rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for lab services provided on March 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 March 19, 2021.