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

 
We decided that the Plan does not have to pay for non-emergency transportation in a wheelchair van (A0130) 
and non-emergency transportation; per mile (S0215) provided on March 16, 2023. 
 
You asked the Plan to pay for non-emergency transportation in a wheelchair van (A0130) and non-emergency 
transportation; per mile (S0215). You say that there is no patient responsibility. You also say that you checked 
the enrollee's benefit Plan and chair vans are a covered service. The Plan denied your request. The Plan says 
this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
  The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation in a wheelchair van (A0130) and non-
emergency transportation; per mile (S0215) provided on March 16, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and mileage provided on April 11, 
2023. 
 You asked the Plan to pay for the ambulance service and mileage. You say that you do not agree with the 
denial of payment for the service. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 8, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service and 
mileage provided on April 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and your daughter called an ambulance to assist. You also say that you can't believe the plan would not pay for 
the bill and are asking for them to pay this claim. The Plan denied your request. The Plan says these services 
are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on July 26, 2023, to July 28, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for observation care. You say that you have attached medical records for review. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-
of-network provider (a provider who is not part of the plans network) will not be covered. 
 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 observation care provided on July 26, 2023, to 
July 28, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management provided on May 31, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the chronic care management. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chronic care management provided on May 31, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatments (98941 x 2) provided on  
June 14, 2021 and June 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as the claims 
were submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that the claims for these services were submitted electronically on August 3, 2021. This 
means that the claims were submitted timely within one calendar year after the dates of service. Therefore, we 
decided that the Plan has to pay for the chiropractic manipulative treatments (98941 x 2) provided on June 14, 
2021 and June 23, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tetanus, Diphtheria, and Pertussis (Tdap) vaccine and the 
administration of the vaccine provided from June 15, 2023, to June 15, 2023. 
 
You asked the Plan to pay for the medication. You say that you were told both shots were needed at your 
yearly physical check-up. You also say that no one mentioned that the Tdap shot would not be covered. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a Tetanus, Diphtheria, and 
Pertussis (Tdap) vaccine and the administration of the vaccine provided from June 15, 2023, to June 15, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction (D7210) provided on June 20, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the provider charged to much money, and 
you would like the Plan to cover the dental charges. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid $130 for dental services on March 16, 2023. On March 31, 2023, the Plan paid $2,158 for 
dental services. On May 2, 2023, the Plan paid $207 for dental services. On June 20, 2023, the Plan paid 
$4,505 for dental services. For the year of 2023 the Plan paid $7,000 ($130 paid + $2,158 paid + $207 paid + 
$4,505 paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was 
exhausted on the date of service of June 20, 2023. Therefore, we decided that the Plan does not have to pay 
more for the extraction (D7210) provided on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic mammogram 
provided on May 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic mammogram. You say that this was a 
screening and should not have a 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 $130 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $130 copayment for an in-network diagnostic mammogram. This item/service 
falls within the outpatient diagnostic tests 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. However, since the allowed amount is less than the standard copayment, 
you only owe $ 107.91. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network diagnostic mammogram provided on May 08, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze (A6219) provided on April 21, 2023. 
 
You asked the Plan to pay for gauze (A6219). You say that the patient was not enrolled in hospital for date of 
service, April 21, 2023. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for gauze (A6219) provided on April 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on July 31, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 a home visit evaluation provided on July 31, 2023, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an  electrocardiogram provided on April 
20, 2023. 
 
You asked the Plan to waive the copayment for an  electrocardiogram. 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 $20 
copayment for outpatient diagnostic tests/Medicare-covered non-radiological diagnostic services. 
 
You have been asked to pay a $20 copayment for an  electrocardiogram. This item/service falls within the 
outpatient diagnostic tests/Medicare-covered non-radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an  electrocardiogram provided on April 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your blood 
pressure dropped and friends were helping you so someone called the ambulance. You also say that the 
ambulance crew checked your blood pressure but you did not want to go to the hospital so they left. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ER services provided on December 24, 2021. 
 
You asked the Plan to pay for ER services. You say that the claim was submitted within the required timeframe 
and should be reprocessed for payment. The Plan denied your request. The Plan says the claim was not 
submitted within 12 months from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for ER services was not filed until April 20, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for ER services provided on December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 28, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory service provided on March 28, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 12, 2023. 
 
You asked the Plan to pay for the office visit. You say that this provider is in the same group as the enrollees 
primary care provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport, 
and ground mileage provided on May 19, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you are requesting to 
reconsider the claim for payment and are seeking for review.  The Plan denied your request. The Plan says 
Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 16, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance service, basic 
life support, emergency transport, and ground mileage provided on May 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tomosynthesis provided on March 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a tomosynthesis. You say that you are asking for the review for the documents 
summitted. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be covered. 
 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 a tomosynthesis provided on March 23, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 19, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on July 19, 2023. 
 
You asked the Plan to pay for a chiropractic visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on July 19, 2023.