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

 
We decided that the Plan does not have to pay for the wheelchair van transportation provided on April 28, 
2022. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you were not aware this service 
would not be covered. The Plan denied your request. The Plan says wheelchair van transportation is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 25, 2022, by an 
OON provider. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the denial of the claim with 
submitted medical records for review in support of the services billed. The Plan denied your request. The Plan 
says the out-of-network services were not authorized. 
 
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 wound care supplies provided on February 25, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership provided on December 8, 2021. 
 
You asked the Plan to pay for a gym membership. You say that this is for a year of classes. You also say that 
this was supposed to go for 2022, not 2021. The Plan denied your request. The Plan says you would need to 
submit a fitness reimbursement request for benefit year 2022 since the Plan received our 2021 fitness 
reimbursement after the cutoff date. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses you up to 
$150 per calendar year towards your cost for membership in a qualified health club or fitness facility, and 
covered instructional fitness classes. Reimbursement requests must be submitted no later than March 31 of the 
following year.  
 
The Plans rules for coverage of gym benefits have not been met because this reimbursement request was 
submitted after March 31, 2022. Therefore, we decided that the Plan does not have to pay for a gym 
membership provided on December 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 15, 2022. 
 
You asked the Plan to pay for the medical service. You say that the patient wasn't on hospice on the date of 
service. The Plan denied your request. The Plan says this claim should go to Original Medicare. 
 
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 May 11, 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 medical services provided 
on May 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Boost High Protein supplement (B4150). 
 
You asked the Plan to pre-approve a Boost High Protein supplement. You say that the boost supplement is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of Boost supplement because there is no documentation that he has sustained involuntary or acute 
weight loss of greater than or equal to 10% of usual body weight during the 6 months prior to date of request. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve a Boost High Protein supplement (B4150).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 19, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says Medicare 
does not pay for this service. 
 
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 self-administered drugs provided 
on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services related to a surgical shoulder 
arthroscopy (29823) billed for date of service April 19, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that you have provided records to support 
the services billed. The Plan denied your request. The Plan says the records do not support the services at issue. 
 
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 29823 is "Arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for assistant at surgery services. Our reviewer says that the assistant at surgery services at issue do not meet criteria for payment. Our reviewer found that the available 
medical documentation does not support the use of procedure code 29823. The areas described were not 
separate or discrete from the joint the provider was performing the arthroscope on. The available medical 
documentation could not determine the use of this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of assistant at surgery services have not been met because the base procedure does 
not meet criteria for payment. Therefore, we decided that the Plan does not have to pay for assistant at surgery 
services related to a surgical shoulder arthroscopy (29823) billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on March 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient surgery services provided on March 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT sessions. You say that the records provided support the 
need for the number of physical therapy visits being requested. The Plan denied your request. The Plan says the 
notes provided do not show why the enrollee needs 3 days a week of physical therapy. The Plan says that a 
lower frequency of care using the 12 physical therapy visits they have approved is more appropriate. 
 
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 PT sessions. 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 the patients condition beyond what was approved by the health 
plan. The patient has had prior therapy and the documentation does not reveal that the patient's requires 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.  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 the patient's 
current condition or to prevent or slow further deterioration. The patient has been instructed in a home program 
and does not require the remaining visits with the skills of a professional therapist. 
 
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 PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on May 16, 
2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you were dissatisfied with 
your care and needed to go to the ER two days later. You want this copayment reduced. 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 $30 
copayment for urgently needed services. 
 
 
 
 
 
 You have been asked to pay a $30 copayment for an urgent care visit. 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 reduce the copayment for an urgent 
care visit provided on May 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from 
November 4, 2021, to November 11, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were told your 
copayments would be $20 and not more. Therefore, you will not pay. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 outpatient hospital services.  
 
You have been asked to pay a $85.50 copayment, rather than the full copayment amount of $150 for physical 
therapy visits. Physical therapy visits 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 physical therapy visits provided from November 4, 2021, to 
November 11, 2021.  Your complaint about the customer service department giving you the incorrect copayment amount 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program provided from December 6, 2021, to 
December 27, 2021. 
 
You asked the Plan to pay for the opioid treatment program. You say that you would like the claim to be paid at 
the Medicare rate. The Plan denied your request. The Plan says that the rendering provider is an out-of-network 
provider and there were in-network providers available that provide the same service. Also, the service 
rendered was not urgent or emergent. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network Therefore, we decided that 
the Plan has to pay for the opioid treatment program provided from December 6, 2021, to December 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met because the service at issue was billed 
with the incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. The case record indicates that the specimen was collected on a date 
other than the billed DOS. In this case, there are no apparent grounds for an exception to the rule. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing (81455) billed for date of service April 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service January 16, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this code should not be bundled with 
anything else. The Plan denied your request. The Plan says payment for code 76775 is bundled into payment 
for code 76776. 
 
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 76775 
is a column II code to column I code 76776 with a modifier indicator of 0. The column II code is therefore not payable. 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 76775 billed for date of service January 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from May 5, 2022, to 
June 15, 2022. 
 
You asked the Plan to reimburse you for psychotherapy. You say that the services should be covered. The Plan 
denied your request. The Plan says this provider has opted out of Medicare. Medicare and the Plan will not pay 
any amount for services obtained from a physician that has opted out of Medicare even if it is a Medicare-
covered service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from May 5, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services provided from May 19, 
2022, to May 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you were admitted to the 
hospital from May 19, 2022, to May 23, 2022, but the Plan denied the inpatient admission and the stay was 
dropped to observation. You say that your condition warranted an inpatient stay and because the stay was 
denied, you were charged several fees. The Plan denied your request. The Plan says the copayment applied 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 $35 
copayment for each specialist visit, including outpatient clinic visits, a $5 copayment for diagnostic lab services 
and diagnostic procedures and tests (per day, per facility) and a $180 copayment for each advanced imaging 
service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests).  
 
You have been asked to pay $110.65 for the following outpatient services.  
 
Date of Service Service Amount 
Billed 
Amount 
Allowed 
Amount per 
Contract 
Members 
Share 
May 19, 2022 & 
May 20, 2022 
Specialist Visit $359.00 $133.42 $35 copayment 
per visit 
$70 
May 19, 2022 Electrocardiogram 
(ECG) 
$49.00 $8.14 $5.00 
copayment 
$5.00 
May 20, 2022 Stress Test $69.00 $35.65 $180 copayment $35.65 
Total     $110.65 
 
Specialist visits, electrocardiogram (ECG), and a stress test 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 outpatient services provided from May 19, 
2022, to May 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 31, 2022, to February 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. 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. The Plan has 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 psychotherapy provided on January 31, 2022, to 
February 28, 2022, by an out-of-network (OON) provider.