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

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on September 18, 
2021. 
 You asked the Plan to pay for the paramedic intercept services. You say that you live one mile from the 
hospital and did not request a paramedic. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on September 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 13, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on September 7, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 97530 is Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the medical record provided 
does not document 15 minutes of therapy provided to the enrollee. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the therapy services (97530) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on October 11, 
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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72020 billed for date of service October 31, 
2021. 
 You asked the Plan to pay for procedure code 72020. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72020 is bundled into payment for 
code 72050. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72020 
is a column II code to column I code 72050. This claim has 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 procedure code 72020 billed for date of service October 31, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper extremity orthosis features (L7499). 
 
You asked the Plan to pre-approve the upper extremity orthosis features. You say that these features are 
medically necessary. The Plan denied your request. The Plan says Medicare billing rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that that code L7499 must not be used for the billing 
of any additional features or components, programming, adjustment, etc. with codes L6026, L6715, L6880, or 
L7007-L7009 as these codes are considered all-inclusive. 
 
We looked at the file and Medicare rules. Code L7499 was submitted for additional features on an L6880 
orthosis. This is considered unbundling. Based on this information, we decided that Medicare rules for 
coverage of the upper extremity orthosis features have not been met. Therefore, we decided that the Plan does 
not have to pre-approve upper extremity orthosis features (L7499).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (74178) 
provided on November 29, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $295 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $295 copayment for a CT scan. CT scans fall 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 a computed tomography (CT) scan (74178) provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract removal procedure (66982) 
performed on July 15, 2021. 
 
You asked the Plan to waive the copayment for the cataract removal procedure. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $250 copayment for a cataract removal procedure. Cataract removal procedures 
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 a cataract removal procedure (66982) performed on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered investigational. More research is needed to show safety 
and efficacy. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on October 21, 2021. 
 
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we 
decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0483) provided on October 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from October 27, 2021, to October 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you thought you were admitted and 
the copayment should be waived. 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 $120 
copayment for each emergency room visit. The cost share will be waived if you are admitted to the hospital 
within 24 hours of the ER visit.  
 The file shows that you were kept overnight under observation status only, not as an inpatient. Therefore, you 
have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 emergency room (ER) visit 
provided from October 27, 2021, to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the routine venipuncture (36415) 
rendered by the out-of-network (OON) provider on September 24, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 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 office visit (99203) and the routine 
venipuncture (36415) rendered by the out-of-network (OON) provider on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation 
(92014) and the eye refraction (92015) rendered by the out-of-network (OON) provider on November 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 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 ophthalmological medical examination and evaluation (92014) and the eye 
refraction (92015) rendered by the out-of-network (OON) provider on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the knee provided on December 
17, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that the copayment is too high. 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 $50 
copayment for X-rays.  
 
You have been asked to pay a $50 copayment for the X-rays. The X-rays fall 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 X-rays of the knee provided on December 17, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) provided 
on November 30, 2021. 
 
You asked the Plan to waive the copayment for the transvaginal ultrasound. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for a transvaginal ultrasound. Transvaginal ultrasounds fall 
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 a transvaginal ultrasound (76830) provided on November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following 
colporrhaphy procedures (57240, 57260). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that it is expected that the enrollee 
will experience issues with urinary retention following this surgery. The provider would like to check post-void 
residuals with ultrasound following surgery and prior to discharge. The Plan denied your request. The Plan says 
the colporrhaphy procedures are considered outpatient procedures and it is not medically necessary to provide 
an inpatient stay with this surgery. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this 
case. Our physician reviewer found that the enrollee has a history of rectocele and cystocele. The provider 
recommended surgical repair, including procedure codes 57240 and 57260. These procedures are considered 
outpatient by Medicare. The provider is requesting that the enrollee be admitted as inpatient for 2 nights 
following surgery, as she expects the enrollee may have issues with urinary retention. The provider plans to 
discontinue the Foley catheter on post-op day 2 and check for post-void residuals with ultrasound prior to 
discharge. The review has determined that the record does not show that at the time of inpatient admission the 
admitting physician reasonably expects that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care to be provided following colporrhaphy 
procedures (57240, 57260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the head with dye 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider must show medical need before this request can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
normal neurological exam, and the rational for ordering this computed tomography (CT) of the brain with 
contrast has not been evident in the submitted records. Head trauma is not documented, and there no known 
malignancy or evidence of cerebrovascular accident. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the head with dye for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on January 11, 2022. 
 
You asked the Plan to pay for the complete dentures. You say that the Plan did not advise you that they were 
discontinuing the dental supplement insurance that you had last year. You also say that you live on a fixed 
income and the Plan should be held responsible for this payment. The Plan denied your request. The Plan says 
these services are not covered expenses under your dental 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.  
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 pay for the 
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on January 11, 2022.