Persius/hicric huggingface dataset:
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 physical and occupational therapy recommend acute 
inpatient rehabilitation to recover from a left trimalleolar fracture and a left patellar fracture. The Plan denied 
your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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 a Tetanus, diphtheria, and pertussis vaccine (Tdap), received 
on May 16, 2023. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you were not aware that this was considered a 
pharmacy item. The Plan denied your request. The Plan says this vaccination is not covered under your contract 
with the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for a Tetanus, diphtheria, and pertussis vaccine 
(Tdap), received on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 8, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis code billed is payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R41.0 has an Excludes1 note in relation to R41.82. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on April 8, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on June 06, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that you had to 
repeat this test, and you should either have to pay a lower copayment or nothing. 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 $290 
copayment for outpatient surgery. 
 
You have been asked to pay a $290 copayment for an in-network diagnostic colonoscopy. This item/service 
falls within the outpatient surgery 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 
an in-network diagnostic colonoscopy provided on June 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 96040. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 96040 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee has been dealing with this for 
over 50 years. You also say that the enrollee has tried conservative treatments. The Plan denied your request. 
The Plan says interspinous process spacers are considered to be investigative due to lack of evidence of 
improved outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 Vertiflex device have been met. 
Specifically, there were no medical records provided to support the medical necessity of the requested service. 
Therefore, we decided that the Plan does not have to pre-approve insertion of Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 11, 2023, and billed with codes 87481 x 4. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on April 11, 2023, and billed with codes 87481 x 4.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network and 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 an office visit provided on April 20, 2023, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on May 30, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that a registered nurse 
endorsed this transport who deemed it medically necessary and the safest and most suitable mode for 
transporting the enrollee to and from the nursing home to the physician's office. The Plan denied your request. 
The Plan says the enrollee's plan covers professional ambulance service for emergency transport only. Since 
the service(s) submitted does not meet this requirement, the service is not covered under the member's plan.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance service and ground mileage was not medically necessary.  Our physician reviewer found the transportation via ambulance to and from the doctor's office was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other 
means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent 
layperson would not believe that immediate medical attention was required for someone who was attending a 
scheduled appointment. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on May 30, 2023.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show complex rehabilitation and 
medical needs. The Plan says that the services needed may be provided safely in a lower level of care.  
 
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 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.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on May 3, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that due to the enrollees 
condition at the time of transport, any other means of transport would be unsafe. The Plan denied your request. 
The Plan says the enrollee did not require the expertise of trained personnel or the equipment available only in 
an ambulance in order to effectuate a safe transport. 
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
enrollee was transported from an acute care facility to a skilled nursing facility via stretcher.  The record does not indicate that the enrollee's condition was such that other methods of transport, such as 
stretcher, are contraindicated or that the expertise, services and lifesaving equipment that only a fully equipped 
ambulance can provide was required. The elements of coverage criteria are not satisfied. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening cytopathology, cervical or vaginal provided on 
April 25, 2023. 
 
You asked the Plan to pay for the screening cytopathology, cervical or vaginal. You say that your last pap 
smear was April 7, 2022. The Plan denied your request. The Plan says Pap smears covered once every 24 
months. 
 
The Plan contract says Pap tests and pelvic exams are covered once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Based on 
this information, we decided that Plans rules for coverage of the screening cytopathology, cervical or vaginal 
have not been met. Therefore, we decided that the Plan does not have to pay for a screening cytopathology, 
cervical or vaginal provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 
13, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to 
pay this copayment since this was not in-person. 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 $45 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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. The record shows this claim was approved and you are responsible for the 
cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the specialist 
office visit provided on July 13, 2022.
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 
February 10, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration for the 
denied claim. 
 The Plan denied your request. The Plan says this provider is out-of-network and 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on January 3, 
2022, to May 31, 2022. 
 
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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a marriage and family therapist (MFT) is not eligible 
to participate in Medicare. 
 
We looked at the file and Medicare rules. The file shows that the services were rendered by a marriage and 
family therapist. This provider type is not eligible to participate in Medicare. Therefore, we decided that the 
Plan does not have to pay for the outpatient mental health services rendered on January 3, 2022, to May 31, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the inpatient hospital services 
provided outside of the country in South Korea beyond $14,391.39 of what the Plan paid.  
 
You asked the Plan to issue additional reimbursement for these services. You say that the Plan should pay more 
of the cost of these services. The Plan denied your request. The Plan says based on the records provided, the 
enrollee was paid the amount that would be paid by Original Medicare, as the Plan contract states.  
 
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 Plan will reimburse for covered out-of-network emergency and 
urgent care services outside of the U.S. and its territories at Original Medicare reimbursement rates.   
 
 
 
The enrollee will be responsible for any costs above what Original Medicare would pay, less any cost-sharing 
for the services the enrollee received. 
 
The enrollees contract with the Plan clearly says that enrollees must pay any costs above what Original 
Medicare would pay for care provided out of the country. This is a supplemental benefit paid at the Plans 
discretion. The Plan has paid $14,391.39 in accordance with the Plans contract rules and based on the rates 
traditionally paid by Original Medicare. Therefore, we decided that the Plan does not have to issue additional 
reimbursement for the inpatient hospital services provided outside of the country in South Korea beyond 
$14,391.39 of what the Plan paid.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for gozetotide on March 15, 2023.  
 
You asked the Plan to waive the cost share for gozetotide. You say that you want to appeal the amount being 
charged. 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 $500 
out-of-pocket maximum. You must pay a 20% coinsurance for each Medicare-covered medical supply. 
Covered services include, but are not limited to surgical supplies, such as dressings. The provider billed in the 
amount of $11,750 and the allowed amount is $5,358 for the service. There is a $408 out-of-pocket amount. 
Therefore, results in the total cost sharing amount of $408. 
 
You have been asked to pay a $408 cost share for gozetotide. This item/service 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 
cost share for gozetotide on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker, a non-covered item or service 
(A9270). 
 
You asked the Plan to pre-approve an upright walker. You say that you would like the requested upright walker 
instead of the standard walker the Plan has approved you for. The Plan denied your request. The Plan says there 
is no documentation that a standard walker would not meet your needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard walker. A standard walker serves the same purpose as an upright 
walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker, a non-covered 
item or service (A9270).