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

 
We decided that the Plan has to pay for ambulance services (A0429 and A0425) proivded on September 14, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this claim was not billed with an 
appropriate diagnosis code. 
 
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 has not provided any evidence to support that the diagnosis 
code billed on the claim is inappropriate for the services rendered. The Plan has not forwarded a claim to show 
what diagnosis codes were billed. The Plan has also not provided any Medicare guidelines or regulations to 
show why this billing would not be supported. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for ambulance services (A0429 and A0425) proivded on 
September 14, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on November 10, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed 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. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on November 10, 
2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have knee 
osteoarthritis. The Zilretta is being requested for its current Food and Drug Administration (FDA) labelled 
indication. The FDA has not restricted its use to a single time. The services are therefore reasonable and 
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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type provided on August 9, 2021, to October 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for automatic external defibrillator, with integrated electrocardiogram analysis, 
garment type. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan, and they have also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 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 automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type provided on August 9, 2021, to October 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you are showing improvement, feel that 
the physical therapy is helping, and you would like more visits. The Plan denied your request. The Plan says 
the documentation does not demonstrate the continued skills of a therapist are required. 
 
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 additional PT 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 additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. Our reviewer found that 
you have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist 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. Our physician reviewer also found 
that the requested services are not part of a maintenance program, and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the provider regularly complies 
with all administrative requirements for payments. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan, and the services were not referred by a network provider or rendered in 
an in-network facility. 
 
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 a hospital outpatient clinic visit provided on 
February 2, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a neurobehavioral status exam provided on 
December 15, 2021. 
 
You asked the Plan to reduce the copayment for the exam. You say that you should only be responsible for the 
$5 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for mental health services.  
 
You have been asked to pay a $35 copayment for the exam. The exam 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 reduce the copayment for a neurobehavioral status exam provided on December 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 15, 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. 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 these 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 the laboratory services rendered on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 6, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the testing services were not ordered by the 
referring provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The records in this case do not show that the lab services were 
ordered by the enrollee's treating physician. The Plan has further confirmed with the providers office that the 
services were not ordered. Based on this information, we decided that Medicare rules for coverage of 
laboratory services have not been met.  
 
 Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the routine transportation services (A0130) 
provided on August 19, 2021. 
 
You asked the Plan to waive the copayment for the routine transportation services. You say that you would like 
reconsideration because you live alone and are not able to walk to your provider. The Plan denied your request. 
The Plan says the cost share assessed is correct. 
 
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 $100 
copayment for Ambulance Services.  
 
You have been asked to pay a $45.90 copayment for each routine transportation trip. Routine transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay less than the 
contracted 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. Please note, the Plan has confirmed that you are not liable for 
payment for the denied service billed with CPT code A0425. Therefore, we decided that the Plan does not have 
to waive the copayment for the routine transportation services (A0130) provided on August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc (J7320). 
You asked the Plan to pre-approve Genvisc. You say that you believe Genvisc is the best alternative for the 
enrollee's specific needs. You also say that you recommend Genvisc because you have seen many patients do 
very well with it, and it is cheaper than the other options. The Plan denied your request. The Plan says the 
requested service does not meet medical necessity criteria as the documentation received did not advise that at 
least one of the preferred brands of Intra-articular hyaluronic acids (Euflexxa, Synvisc, or Synvisc-One) was 
ineffective, not tolerated, or is not a treatment option. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc. Our reviewer says that 
Genvisc is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our 
reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc (J7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 3, 2021. 
You asked the Plan to pay for the eye refraction. You say that this was an in-network provider, and you 
expected this service to be covered. The Plan denied your request. The Plan says eye refractions are only 
covered when they are received as part of a routine eye exam performed by a provider in the specified routine 
vision vendor network. 
 
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 these services when they are provided as part of a routine eye exam by a provider in 
the specified routine vision vendor network. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was provided alongside a medical 
(non-routine) eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4211), four periodontal 
scalings and root planings (D4341 x4), and surgical extraction (D7210) provided on December 16, 2021 by a 
periodontist. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty, scalings and planings, and surgical 
extraction. You say that you are on a fixed income and would like to appeal the charges for these services. The 
Plan denied your request. The Plan says there is no coverage for when services are rendered by a specialist. 
 
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 
covered when they are received by a specialist. Therefore, we decided that the Plan does not have to pay for the 
gingivectomy or gingivoplasty (D4211), four periodontal scalings and root planings (D4341 x4), and surgical 
extraction (D7210) provided on December 16, 2021 by a periodontist.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
19, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were never told you 
would be responsible for a copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for in-network Medicare-covered ambulance transport.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$200 copayment for ambulance services. Ambulance services 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 services provided on November 19, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801, 87150) provided November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 (87801, 87150) provided November 1, 2021.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for a patient domiciliary, rest home visit provided on December 21, 2021. 
 
You asked the Plan to pay for the patient domiciliary, rest home visit. You say that the member is currently 
living and was seen at an independent living center for a routine evaluation and management. You say that this 
provider is contracted with the facility to see their residents The Plan denied your request. The Plan says that 
the member elected Hospice services beginning April 17, 2020. 
 
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 has not provided us with proof of Hospice enrollment. 
Therefore, we decided that the Plan has to pay for a patient domiciliary, rest home visit provided on  
December 21, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on 
October 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not covered. 
 
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 paramedic 
intercept services provided to the enrollee on October 20, 2021.