Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 10, 2021 by 
an out-of-network (OON) provider. 
You asked the Plan to pay for the physical therapy services. You say that you would like payment to be 
processed for this claim. The Plan denied your request. The Plan says both the referring and rendering 
providers are non-participating with the Plan. The Plan also says that prior authorization was not obtained. 
 
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 the physical therapy services provided on June 10, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for a tail gate lift for chair transport. 
 
You asked the Plan to pay for a tail gate left. You say that a tail gate life was medically necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not cover self-help devices to facilitate using equipment 
outside of the home.  
 
A tail gate lift is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for to pay 
for a tail gate lift for chair transport.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 22, 2021 by 
an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the physical therapy services. You say that you would like payment to be 
processed for this claim. The Plan denied your request. The Plan says both the referring and rendering 
providers are non-participating with the Plan. The Plan also says that prior authorization was not obtained. 
 
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 
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 physical therapy services provided on July 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for non-emergency ambulance transport (A0428) and ground mileage 
(A0425) provided on August 11, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that transport to a non-covered destination is not covered. 
 
Please note: The Plan's denial rationale is not applicable. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have been met. Specifically, the file indicates that the enrollee was 
transported to a skilled nursing facility (SNF) which is a covered destination. Therefore, we decided that the 
Plan has to pay for non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on 
August 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services, medical 
examination provided on September 22, 2021. 
 
You asked the Plan to waive the copayment for ophthalmological services, medical examination. The Plan 
denied your request. The Plan says the claim processed with the correct copayment. 
 
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 $45 
copayment for Vision Care, Medicare-covered exam to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $45 copayment for ophthalmological services, medical examination. The 
ophthalmological services, medical examination falls within the Vision Care, Medicare-covered exam to 
diagnose and treat diseases or conditions of the eye 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 ophthalmological services, medical examination provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that all you received was a 
shot and you should be covered with no copayment. The Plan denied your request. The Plan says the proper 
copayment was applied for this service. 
 
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 $25 
copayment for each covered specialist office visit.  
 
  You have been asked to pay a $25 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner services, including doctor's 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 a specialist office visit provided on November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography guidance for placement of radiation 
therapy fields (77014) provided September 13, 2021 to September 16, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that daily charges for CPT code 77014 should be 
allowed, as these imaging procedures are performed daily and checked daily by the treatment physician. The 
Plan denied your request. The Plan says service is considered incidental to the total episode of care. 
 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 77301 
is a column II code to column I code 77014. 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 computed tomography guidance for placement of radiation 
therapy fields (77014) provided September 13, 2021 to September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on November 19, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services provided to the 
enrollee was medically necessary and the claim should be paid. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider with no referring provider or an approved authorization. 
Also, the services rendered by the provider was not urgent or emergent. 
 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 hospital services provided on 
November 19, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $224.32 copayment charged for magnetic resonance 
imaging (MRI) provided on October 16, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is less than the normal copayments expectation of 
$275. 
 
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 $275 
copayment for outpatient radiology. Based on the claim submitted by the provider, you are actually being 
charged less than the normal copayment expectation. 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 $224.32 
copayment charged for magnetic resonance imaging (MRI) provided on October 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the upper endoscopy with biopsy (43239) 
provided on October 12, 2021, and the colonoscopy with removal of tumors, polyps or other lesions (45384) 
provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy and colonoscopy services. You say that these 
procedures were necessary and cancer-related, and you feel your costs should be removed or lowered. The Plan 
denied your request. The Plan says these services are covered by your Plan. Outpatient surgical procedures 
provided in an ambulatory surgical center require a $325 copayment per visit. These claims were processed 
correctly, and your copayments were assessed in accordance with your contract. 
 
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 for each Medicare-covered ambulatory surgical center visit.  You have been asked to pay a $325 copayment or less for each of the surgical procedures provided in an 
ambulatory surgical center. 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 upper endoscopy with 
biopsy (43239) provided on October 12, 2021, and the colonoscopy with removal of tumors, polyps or other 
lesions (45384) provided on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 12, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 6, 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 provider did not bill 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 11721 is a column II code to column I code 11055. 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 surgical services provided to the enrollee on July 6, 2021.
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. The Plan denied your request. The Plan says IRF admission is 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 considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found that based on the medical records provided the complexity of the enrollee's 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollees medical conditions are reported to be stable on 
outpatient medications with no issues that require a physicians evaluation three or more times per week. The 
enrollee does require physical therapy and occupational therapy services, but based on the medical records 
provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the 
medical records provided there is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. Care in the home with home health services or 
at the skilled nursing facility level appears to be appropriate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213), correction of trichiasis; epilation 
(67820), and the determination of refractive state (92015) provided on September 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit, correction of trichiasis; epilation, and the determination of 
refractive state. You say that you were told by the doctor's office that he participated in your insurance, so you 
made the appointment. The Plan denied your request. The Plan says the provider is a non-participating provider 
with the Plan, and the enrollee must receive services by a participating provider, with three exceptions. The 
Plan also says that the three exceptions do not apply in the enrollee's circumstances, since the services do not 
qualify as urgent/emergent, and the Plan was not contacted for prior-approval. 
 
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 (99213), correction of trichiasis; 
epilation (67820), and the determination of refractive state (92015) provided on September 21, 2021, by an out-
of-network (OON) provider.  
 
Your complaint about the potentially poor customer service received  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 9, 2020, to July 29, 2020. 
 
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 there is no documentation found to support the coding of Section GG items needed to generate a 
usual function score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
We find that the denied services are not supported in the medical record. The provider coded a score of 15 for 
the PT/OT functional score and a 10 for the nursing functional score. There does not appear to be any 
supporting documentation for these scores. 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 skilled 
nursing facility (SNF) services provided to the enrollee from July 9, 2020, to July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on October 8, 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 chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor sensor. You say that this is 
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre continuous glucose monitor sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 7, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this vision 
service is not covered by this medical plan. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.   
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on October 7, 2021.