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

We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on July 11,
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 the enrollee was hemodynamically stable.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the
documentation does support that the enrollee suffers from an illness or injury that contraindicates transportation
by any means other than ambulance. The documentation does not support that the enrollee's condition was such
that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a
threat to the patient's survival or seriously endangered the enrollee's health. Ground transport would have
provided an earlier arrival at the hospital.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for air ambulance services provided to the enrollee on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 28, 
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 Current Procedural Terminology (CPT) code 83789-59 (1 Unit) remains not supported. 
 
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 83789 is "Mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen." 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code cannot be 
separately reimbursed when billed for specimen validity testing on specimens used for drug testing. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on June 28, 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 office visit (99213) rendered by the out-of-network (OON) provider on June 28, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99281) provided August 15, 2021. 
 
You asked the Plan to pay for the emergency room visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the service was dental in nature and is non-covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
 
 
 
  
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99281) 
provided August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on August 2, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. You say that you thought that you were saving money 
for the Plan. The Plan denied your request. The Plan says there is no listed benefit for eyeglasses to be 
purchased from an out-of-network provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by a participating vision care provider. 
 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a Plan 
participating vision care provider. Based on this information, we decided that the Plan's rules for coverage of 
the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
eyeglasses provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for copayments for prescription drug and pharmacy 
purchases under the Pick-Your-Perks program. 
 
You asked the Plan to reimburse you copayments. You say that the Plan should reimburse you for copayments 
under the pick your perks program. The Plan denied your request. The Plan says copayments are a contractual 
obligation and are not reimbursable under the perks program. 
 
 
 
 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Copayments and coinsurance are a contractual obligation and are 
not listed as reimbursable in the pick your perks program. Copayments and coinsurance are contractual cost 
share you agree to pay when you became a member of the Plan. Therefore, we decided that the Plan does not 
have to reimburse you for copayments for prescription drug and pharmacy purchases under the Pick-Your-
Perks program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted case management (T1017) rendered by the out-
of-network (OON) provider on August 28, 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 targeted case management (T1017) rendered by the out-of-network (OON) 
provider on August 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a sacroiliac (SI) joint injection. You say that the requested sacroiliac (SI) 
joint injection is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac (SI) 
joint injection is not medically necessary. 
 
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 a sacroiliac (SI) joint injection. Our 
reviewer says that the requested sacroiliac (SI) joint injection is not medically necessary. Our physician 
reviewer found the clinical value and effectiveness of an SI joint injection in the absence of tenderness and 
negative provocative testing results have not been demonstrated in the peer-reviewed literature.  In this case, 
there is no documentation on physical examination of tenderness to the SI joint and no mention of SI 
provocative testing being completed with positive findings. The review has determined that the requested 
sacroiliac (SI) joint injection is not medically reasonable or necessary for the enrollee in this case. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac (SI) joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home oxygen provided on August 16, 2021. 
 
You asked the Plan to pay for the home oxygen. You say that home oxygen was medically necessary. The Plan 
denied your request. The Plan says the documentation submitted does not address the required coverage criteria 
of oxygen saturation level. 
 The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
We looked at the file and Medicare rules. In this case, there is no documentation that indicates the enrollees 
blood gas levels. Based on this information, we decided that Medicare rules for coverage of the home oxygen 
have not been met. Therefore, we decided that the Plan does not have to pay for the home oxygen provided on 
August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request for additional facet joint injections is not medically necessary because the 
records do not show a minimum of 80% pain reduction with prior facet joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you under the Pick Your Perks reimbursement program 
for S-Acetyl Glutathione 120 C provided on October 25, 2021. 
 
You asked the Plan to reimburse you under the Pick Your Perks reimbursement program for S-Acetyl 
Glutathione 120 C. The Plan denied your request. The Plan says based on the members benefit plan and the 
Pick Your Perks program for 2021, S-Acetyl Glutathione 120 C is not a covered over-the-counter supplement. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says ineligible items 
include but are not limited to the following: Alternative medicines such as botanicals, herbals, probiotics and 
nutraceuticals. 
 
We looked at the file and the Plans rules. The file shows that over-the-counter items must be included on the 
Plans allowed items list. Ineligible items include but are not limited to the following: Alternative medicines 
such as botanicals, herbals, probiotics and nutraceuticals.  Therefore, we decided that the Plan does not have to reimburse you under the Pick Your Perks reimbursement 
program for S-Acetyl Glutathione 120 C provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on September 14, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were not told in advance of 
the 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 $150 
copayment for outpatient surgery at an outpatient hospital.  
 
 You have been asked to pay a $150 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cataract surgery provided on September 14, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14301) on August 6, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer (14301). You say that these are medically necessary 
services for the full care and treatment of the patient's condition. You say that the medical records should be 
reviewed, and the claim should be reprocessed. The Plan denied your request. The Plan says CPT code 14301 
is not supported in the documentation and is not payable. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
  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 the adjacent tissue transfer (14301). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the operative report does not include documentation of an adjacent tissue transfer or rearrangement; 
therefore, the procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the adjacent tissue transfer (14301) have not been met. Therefore, we decided 
that the Plan does not have to pay for the adjacent tissue transfer (14301) on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) and intraoral complete series 
(D0120), provided on October 12, 2021. 
 
You asked the Plan to pay for the prophylaxis and intraoral complete series. You say that the services should be 
covered. The Plan denied your request. The Plan says you received care from a dentist who has opted out of 
Medicare. 
 
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 
prophylaxis (D1110) and intraoral complete series (D0120), provided on October 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive to the copayment for an emergency room visit provided on 
September 20, 2021. 
 
You asked the Plan to waive to the copayment for an emergency room visit. You say that you checked into the 
emergency room but were never seen. 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 $90 
copayment for an emergency room visit.  
 
 
  The records show you were checked in and triaged at the emergency room on September 20, 2021. You have 
been asked to pay the allowed amount of $71.63 which is less than the $90 copayment for an emergency room 
visit. An emergency room 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 to the copayment for an emergency room visit provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultralightweight wheelchair for the enrollee. 
 
You asked the Plan to pre-approve an Ultralightweight wheelchair. You say that Ultralightweight wheelchair is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the medical records provided 
are insufficient to show the need for an Ultralightweight wheelchair 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for the requested wheelchair. The 
records provided do not show the enrollee meets all of the required criteria stated in the Medicare rules section 
of this letter. Medicare rules for coverage of an Ultralightweight wheelchair have not been met.  
 
 Therefore, we decided that the Plan does not have to pre-approve an Ultralightweight wheelchair for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on 
October 6, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination. The Plan denied your request. 
The Plan says 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 Plan says that 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 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 ophthalmological services, medical examination provided on 
October 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 5, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed 
based on updated guidance. The Plan denied your request. The Plan says required documentation is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services provided on 
January 5, 2021. have not been met. In this case, no medical records have been submitted to corroborate the 
services as billed. Therefore, we decided that the Plan does not have to pay for the home health services provided on January 5, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from May 24, 2021, 
through May 26, 2021, and billed with diagnosis-related group (DRG) 640. 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports 
payment for DRG 640. The Plan denied your request. The Plan says the billed diagnosis does not support 
payment for DRG 640. The more appropriate DRG code that will be paid is 683. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 640. We looked at the file and Medicare rules. 
The diagnosis of acute kidney injury is not found within DRG 640. Payment cannot be made for the services as 
billed. Based on this information, we decided the medical records do not substantiate the DRG as billed. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from May 24, 
2021, through May 26, 2021, and billed with diagnosis-related group (DRG) 640.