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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided August 23, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transport and ground mileage. You say that this 
service should be covered. The Plan denied your request. The Plan says payment is not allowed for this service 
because it is not appropriate for the diagnosis billed. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport and 
ground mileage. Our reviewer says that the non-emergency ambulance transportation on August 23, 2021, was 
not medically necessary. Our physician reviewer found the review has determined that the documentation did 
not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type 
of vehicle) were contraindicated for this enrollee on August 23, 2021. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide for safe transport on August 23, 2021.  
 
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 non-emergency ambulance transport and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-
emergency transport (A0428) and ground mileage (A0425) provided August 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health provided on February 15, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 Mental Health provided on February 
15, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested hip 
surgery is not medically reasonable and necessary at this time. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 69-year-old female being treated for primary osteoarthritis of the 
left hip; primary osteoarthritis of the right hip; right hip pain; left hip pain; left lateral knee pain; pain in right 
knee joint. At this time, detailed documentation is not evident regarding advanced osteoarthritis of the hip. The 
February 9, 2022, magnetic resonance arthrogram of the left hip showed mild bilateral hip joint degenerative 
changes. Also demonstrated was a complete tear of the base and substance of the left superior acetabular 
labrum. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested left total hip 
arthroplasty, in this case, is not medically reasonable or 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 a total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found you were admitted to the hospital 
for chronic obstructive pulmonary disease (COPD) and respiratory failure. You are now medically stable with 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601) purchased August 2, 2021. 
 
You asked the Plan to pay for a CPAP device. You say that your old CPAP that was purchased May 12, 2011 
was included in a recall. You were informed that replacement machines would be availing within a year. You 
decided to purchase a new CPAP right away and you request reimbursement. The Plan denied your request. 
The Plan says the CPAP was purchased from a supplier that is not a Medicare provider. If you go to a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure 
(CPAP) device (E0601) purchased August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient cataract surgery performed 
on November 18, 2021. 
 
You asked the Plan to waive the copayment for the outpatient cataract surgery. You say that you shouldn't be 
charged the same price as a full cataract surgery when you were only in the chair for 7 minutes. The Plan 
denied your request. The Plan says the copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 per day for outpatient procedures and services, including, but not limited to, outpatient surgery 
performed in an outpatient hospital or ambulatory surgical center.  The enrollee has been asked to pay $250 for the outpatient cataract surgery. The outpatient cataract surgery 
falls within the Outpatient hospital services benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the outpatient cataract surgery performed on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on November 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. 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 the services 
(99100) provided on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT provided on May 10, 2021. 
 
You asked the Plan to waive the copayment for the CT. You say that you do not think you should have to pay 
the copayment. You say that you would not have had the test if you had known you would have such a high 
copayment. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 
 You have been asked to pay $207.19, which is less that the $325 copayment for the CT. The CT falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the CT provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are 
met. 
 
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 not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
He had physical therapy and is doing a home exercise program. He underwent a transforaminal ESI at L5 and 
had near resolution of pain for six weeks. The Medicare criteria requires 50 percent pain relief for three 
months. The records do not show that the enrollee met this criteria; therefore, the repeat ESI is not reasonable 
or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a foot brace provided on January 28, 2022. 
 
You asked the Plan to waive the coinsurance for a foot brace. You say that you received the foot brace from 
surgery. You say that you found the same item on-line and you expected to pay 20% of that cost. The Plan 
denied your request. The Plan says you have been charged the correct coinsurance 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 20% 
coinsurance for covered items and related supplies.  
 
 
 
 You have been asked to pay $65.11, which is 20% of the allowed amount for the foot brace. The allowed 
amount is $325.53 (20% x $325.53 = $65.11). The foot brace falls within the Durable medical equipment 
(DME) and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a foot 
brace provided on January 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intravenous infusion provided on 
December 4, 2021, through December 13, 2021. 
 
You asked the Plan to waive the copayment for intravenous infusion. You say that you were not aware of any 
cost for these services. The Plan denied your request. The Plan says coinsurance 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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 You have been asked to pay $1,908.30 for intravenous infusion ($190.83/visit x 10 = $1,908.30). You were 
billed $190.83 per visit which is less than the standard $325 per visit copayment. Intravenous infusion falls 
within the Outpatient Surgery and Other Medical 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 intravenous 
infusion provided on December 4, 2021, through December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on December 2, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services should be 
covered. The Plan denied your request. The Plan says the services were denied correctly. 
 
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 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 the rest home visit (99336) provided on December 
2, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pelvic and perineal 
pain. The records do not indicate the occurrence of acute injury. There is no evidence of red flag symptoms or 
physical findings. The MRI is not reasonable or medically necessary for the diagnosis and treatment of the 
enrollee's clinical situation. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic footwear, ladies shoe, oxford (L3215) and 
sales tax (S9999) purchased December 24, 2021. 
 
You asked the Plan to pay for the foot orthotics. You say that you were diagnosed with plantar fasciitis and the 
podiatrist recommended a specific brand of shoe and wrote a prescription. The doctor referred you to a lab that 
does not participate in any insurance plan. The Plan denied your request. The Plan says the items was 
purchased from a provider that is not participating in Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the orthopedic footwear, ladies shoe, 
oxford (L3215) and sales tax (S9999) purchased December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on January 17, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you have a letter from the 
health plan saying that there would be a $0 copayment for the visit. The Plan denied your request. The Plan 
says the copayment was applied 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 $25 for 
each covered telehealth visit or consultation in an outpatient location with a specialist. 
 
 You have been asked to pay $25 for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctors office visits 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 the telehealth visit provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) to replace tooth #30. 
 
You asked the Plan to pre-approve a pontic. You say that you were pre-approved for these services in 2021 but 
did not have them done as the tooth was not bothering you at this time. You changed to a different Plan in 2022 
and changed back after a few months because you were unhappy with your coverage. You figured this would 
be covered as it was pre-approved before. The Plan denied your request. The Plan says a pontic is a prosthetic 
service. There is a 24 consecutive month waiting period that applies to prosthetic services under your dental 
insurance plan. Waiting periods apply for prosthetics replacing teeth that were missing prior to your effective 
date under your current dental plan. You became effective under your current dental Plan on March 1, 2022, 
and you were missing this tooth before this date. You have not yet been enrolled for more than 24 consecutive 
months; therefore, you do not qualify for prosthetic services to replace this tooth at this time. 
 
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. The Plan says that there is a 24-month waiting period which applies to coverage for prosthetics for teeth that were missing prior to 
enrollment. 
 
We looked at the file and the Plans rules. The record shows that you were missing this tooth before your 
enrollment in this Plan on March 1, 2022. You were enrolled with another insurance carrier for two months 
before re-enrolling in this Plan, and therefore you have not met the requirement of 24 months of consecutive 
enrollment for these services. Based on this information, we decided that the Plans rules for coverage of dental 
prosthetics for previously missing teeth have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pontic (D6240) to replace tooth #30.