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

 
We decided that the Plan does not have to pay for office visit provided on June 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that there was no payment on the claim and you would like 
the claim to be reprocessed and paid. The Plan denied your request. The Plan says the enrollee can get the care 
from a network provider and the services were not referred by a network provider. 
 
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 office visit provided on June 16, 2022, by an out-
of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on July 15, 2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $50 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed services are 
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. 
 
 
 
 You have been asked to pay a $50 copayment for urgent care. This item/service falls within the Urgently 
needed 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 urgent care on July 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you need this to go to stores. The Plan 
denied your request. The Plan says this is not covered for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0382) provided on July 27, 
2022. 
 
You asked the Plan to pay for the routine disposable supplies. The Plan denied your request. The Plan says this 
service is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the routine disposable supplies (A0382) provided on July 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Mounjaro is not covered under your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mounjaro.  
 
Benefits for Mounjaro may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient surgery provided on July 12, 
2022. 
 
You asked the Plan to waive the deductible for an outpatient surgery. You say that you are don't think you 
should have to pay the full amount. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Section 1.2 What is your plan 
deductible? 
 
The item or service you asked the Plan to waive the copayment. The total amount you are being asked to pay 
for the outpatient surgery is $353.52 towards your $750 deductible. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a contractual obligation 
that had not been met at the time an outpatient surgery was received on July 12, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for an outpatient surgery provided on July 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on December 28, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you feel you should be compensated 
the full amount for this claim. The Plan denied your request. The Plan says these medications are not among 
the types which are covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on December 28, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation and 
emergency room visit provided on May 23, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation and emergency room visit. You 
say that your initial blood tests were incorrect, and you should not have been transferred to the medical center. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $80 
copayment for each Medicare-covered one-way trip via ground or air ambulance and a $100 copayment for 
each emergency room visit.  
 
 
  You have been asked to pay a total copayment of $260 for a round trip ambulance transportation and 
emergency room visit. The total includes an $80 copayment per ambulance trip (x 2 trips = $160) and a $100 
copayment for the emergency room visit. The ambulance transportation item/service falls within the 
Ambulance Services benefit category. The emergency room visit item/service falls with 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 copayments for the ambulance transportation 
and emergency room visit provided on May 23, 2022.  
 
Your complaint about the initial blood test being incorrect and causing copayments for the ambulance and 
emergency room to occur is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 28308 & 73630 billed for date of service 
January 4, 2022. 
 You asked the Plan to pay for procedure codes 28308 & 73630. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 28308 & 73630 is bundled into 
payment for codes 28645 & 28750. 
 
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 
28308 & 73630 are column II codes to column I code 28645 & 28750. 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 codes 28308 & 73630 billed for 
date of service January 4, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 9, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the members 
terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care 
from the effective date of election to the date of discharge or revocation. During the election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 3, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
April 9, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
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 criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. However, the 
Plan offers a supplemental benefit for special services for the chronically ill when at high risk for 
hospitalization and intensive care coordination is required. 
 
We looked at the file and the Plans rules. The file shows that you have a qualifying condition of diabetes; however, you are not at high risk for hospitalization and do not require intensive care coordination. Based on 
this information, we decided that the Plans rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health care visit provided on 
August 15, 2022. 
 
You asked the Plan to waive the copayment for a mental health care visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for outpatient mental health care.  
 
You have been asked to pay a $35 copayment for a mental health care visit. The total amount you are being 
asked to pay $70 ($35 x 2lines = $70). This item/service falls within the outpatient mental health 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 a mental health care visit provided on August 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic treatment. 
 
You asked the Plan to pre-approve chiropractic treatment. You say that you had a laminectomy done on 
December 17, 2019 and chiropractic treatment helps with your pain. The Plan denied your request. The Plan 
says the submitted documentation indicates that you are requesting these services for chronic low back/gluteal 
pain rather than manual manipulation of the spine to correct subluxation (a slight misalignment of the 
vertebrae). 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic treatment.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 6, 
2021, to December 3, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that you are requesting reconsideration for 
services. You say that due to complications from Hurricane Ida and Covid-19, the member when out-of-
network to receive necessary services. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 6, 2021, to December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on October 2, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need to be transported to the 
hospital and the cost of the service provided is too high. The Plan denied your request. The Plan says this 
service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on October 2, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided on October 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested power scooter cannot be used in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say that prior to or at the time of delivery of a power 
mobility device, the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to 
verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, 
doorway width, doorway thresholds, and surfaces. 
 
The home assessment included in the case file shows that the requested power scooter is not able to be used in 
your home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside 
the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral neurostimulator pulse generator/receiver. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary for phantom limb 
pain. The Plan denied your request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that rules say that current peer-reviewed data does 
not support peripheral nerve stimulation (PNS) for phantom limb pain.  
 
This request is not considered reasonable or necessary for your condition. Based on this information, we 
decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral neurostimulator pulse generator/receiver.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine; 
without contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have lumbar radiculopathy. The record indicates that you had the requested test in August 
2022. The record provided does not indicate the presence of red flag symptoms, abnormal neurological 
findings, or that you have failed a trial of conservative treatment. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine; without contrast material (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiograph provided on March 9, 
2022. 
 
You asked the Plan to waive the copayment for an echocardiograph. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for in-network outpatient diagnostic tests/advanced imaging services.  
 
You have been asked to pay a $150 copayment for an echocardiograph. This item/service falls within the in-
network outpatient diagnostic tests/advanced imaging 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 an echocardiograph provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on August 1, 2022. 
 
You asked the Plan to pay for the eyewear. You say that this is the first time you are using your eyewear 
benefit with this insurance, and you do not understand why the claim was denied. The Plan denied your 
request. The Plan says you have exhausted your eyewear allowance for 2022. The Plan also says the $200.00 
was already paid by the Plan, and the remaining amount is your responsibility to pay. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 per calendar year for routine contacts or eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you exhausted this $200 
allowance during this visit on August 1, 2022. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyewear purchased on August 1, 2022.