Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedures you received in 
your pain management doctor's office on April 27, 2021, and June 8, 2021. 
 
You asked the Plan to waive the copayment for the injection procedures. You say that you thought the 
copayment only applied to office visits, not injections or procedures. The Plan denied your request. The Plan 
says you were charged these copayments 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 $15 
copayment for medical or surgical services furnished in a physician's office.  
 
You have been asked to pay a $15 copayment for the injection procedures. The injection procedures fall within 
the medical or surgical services furnished in a physician's office 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 the injection procedures you received in your pain management doctor's office on 
April 27, 2021, and June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays coded A4550, the additional supplies, 
materials, and clinical staff time over and above those usually included in an office visit or other non-facility 
service(s) coded 99072, the electrodes coded A4556, lead wires coded A4557, and the surgical supplies coded 
A4649 provided on December 17, 2020. 
 
You asked the Plan to pay for the surgical trays, the additional supplies, materials, and clinical staff time over 
and above those usually included in an office visit or other non-facility service(s), the electrodes, lead wires, 
and the surgical supplies. You say that you would like the plan to reconsider their denial The Plan denied your 
request. The Plan says the services are not payable as 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.  

We find that CPT codes A4550, 99072, A4556, A4557, and A4649 are not supported in the medical record. 
Specifically, codes A4550 and 99072 have status indicators of "B". This means that payment for these services 
is always bundled into payment for other services not specified and no separate payment can be made. 
Codes A4556, A4557, and A4649 have status indicators of "P". 

This also means that payment for these services is always bundled into payment for other services not specified and no separate payment can be made. 
Based on this information, we decided that Medicare rules for coverage of the surgical trays, the additional 
supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-
facility service(s), the electrodes, lead wires, and the surgical supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical trays coded A4550, the additional supplies, 
materials, and clinical staff time over and above those usually included in an office visit or other non-facility 
service(s) coded 99072, the electrodes coded A4556, lead wires coded A4557, and the surgical supplies coded 
A4649 provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the gadobenate dimeglumine injection (A9577) provided on June 8, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the service provided.
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 supplied sufficient information, such as an Explanation of Benefits Statement, to show that you had not met your quarterly out of pocket maximum for Medicare Part B drugs administered. Therefore, we decided that the Plan has to waive the coinsurance for the gadobenate dimeglumine injection (A9577) provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 16, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy.
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has
not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 radiation therapy. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the delivery of 20 fractions of radiation in the metastatic setting (as used in STAMPEDE)
seems within the standard of care. Intensity-modulated radiation therapy (IMRT) would be considered the
standard means to deliver prostate radiation in an effort to minimize toxicity risks.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to preapprove
radiation therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and mileage 
(A0425), provided on June 19, 2021. 
 
You asked the Plan to pay for the non-emergent ambulance transport and mileage. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 non-emergent ambulance transport and 
mileage. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully equipped ambulance can provide for safe transport. 
 
 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 non-emergent ambulance transport and mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) 
and mileage (A0425), provided on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker tray. 
 
You asked the Plan to pre-approve a walker tray. You say that you cannot carry food to the table without some 
sort of device for your walker. The Plan denied your request. The Plan says that this is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 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 walker tray.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Plan did not provide plan documentation or medical records. Without this documentation, the Plan denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pre-approve physical therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that you have stabilized 
medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled 
therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. 
You are medically stable without any acute exacerbations of chronic medical problems. Your physical function 
is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for 
inpatient skilled rehabilitation services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
April 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an unspecified preventive procedure. You say that the crown is a covered item 
under the Plan and the additional information that was requested has been provided. You are requesting 
reconsideration of payment. The Plan denied your request. The Plan says the service at issue is not a covered 
benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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. The unspecified preventive procedure is not a covered benefit of 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for an unspecified preventive 
procedure (D1999) provided on April 1, 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 services provided by an out-of-network provider on June 
25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 25, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 24, 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 are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on June 16, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services should be 
included in your annual physical. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that the annual physical does not include lab services. 
 
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 lab tests.  
 
 You have been asked to pay a $10 copayment for the lab services. According to your Evidence of Coverage, 
the annual physical only includes a bodily systems examination, measurement and recording of vital signs, a 
complete prescription medication review, and a review of any recent hospitalizations. It does not include lab 
tests. Separate cost sharing can apply for these lab services. 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 lab services you received on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 27, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you prefer to see this doctor because they have been 
your primary care doctor for years. The Plan denied your request. The Plan says unauthorized, non-plan care is 
not covered. 
 
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 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 office visit provided on May 27, 2021, by an 
OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says before any more therapy can be approved, there needs be a report from the 
doctor about progress and home exercises. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for your condition. You have had prior extensive therapy for this condition and the records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. Given the documentation of at least 56 therapy visits in 2021, you should be able to 
perform an independent home exercise program. You have been instructed in and is compliant in a home 
exercise program. The requested services are not part of a maintenance 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for AlloSure testing provided on January 19, 2018.
You asked the Plan to pay for AlloSure testing. You say that this test is covered by Medicare and the enrollee
meets the requirements of coverage. The Plan denied your request. The Plan says that the denial of payment for
this testing is correct, because supporting documentation did not include clinical suspicion of rejection.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or outof-
network with the Plan. The documentation submitted does not include prior notice from the Plan that this
testing would not be covered. This testing was covered by Medicare for this date of service. Without this
information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the
Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules.
Therefore, we decided that the Plan has to pay for AlloSure testing provided on January 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the frames (V2020), lens (V2784), and sales tax (S9999), 
provided on June 26, 2021. 
 
You asked the Plan to pay for the eyewear and sales tax. You say that the eyewear should be covered. The Plan 
denied your request. The Plan says there is a $150 allowance for eyewear which has been paid and there is no 
coverage for sales tax. 
 
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 has a $150 benefit allowance for eyewear. 
 
We looked at the file and the Plan's rules. The Plan's maximum allowance for eyewear is $150 which has been 
paid and sales tax is not a covered benefit. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear and sales tax have not been met. Therefore, we decided that the Plan does not have to 
pay for the frames (V2020), lens (V2784), and sales tax (S9999), provided on June 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on March 16, 2021. 
 
You asked the Plan to pay for the medical services. You say that these claims should be reprocessed and 
approved for payment. The Plan denied your request. The Plan says these claims must be corrected and 
resubmitted in order to be paid. 
 
The Plan must follow Medicare rules. Medicare rules state that a code with Status Indicator S or T billed on the 
same day as a line item containing an E&M code without modifier 25 results in an I/OCE edit of 21, meaning 
that the whole claim will be rejected and returned to the provider until the error is corrected. 

We looked at the file and Medicare rules. We reviewed the I/OCE Specifications file for this date of service. 
OCE Edit 21 is invoked when a code with a Status Indicator of S or T is billed on the same day as an EM code 
without modifier 25. The required disposition for a claim with this edit is Return To Provider. This means the 
whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected. 
Based on this information, we decided that Medicare rules for coverage of outpatient hospital services have not 
been met. Based on this information, we decided that Medicare rules for coverage of the medical services have 
not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services 
provided on March 16, 2021.