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

 
We decided that the Plan does not have to pay for paramedic intercept services provided on April 5, 2023. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you fainted and an ambulance was 
called. You also say that you feel you do not need to pay this as you did not go to the hospital.  The Plan denied your request. The Plan says paramedic charges when the enrollee is not transported by the 
ambulance supplier and are not covered by Medicare in this case. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient rehabilitation service 
provided on April 03, 2023, to May 26, 2023. 
 
You asked the Plan to waive the copayment for each outpatient rehabilitation service. You say that the enrollee 
should not be responsible for therapy copayments that were only received because the Plan did not allow 
additional time in a skilled nursing facility. 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 $15 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $15 copayment for each outpatient rehabilitation service. This item/service falls within the outpatient rehabilitation 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 each outpatient rehabilitation service provided on April 03, 2023, to May 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says  an MRI of the lower 
extremity is 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 an MRI. Our reviewer says that an MRI 
of the lower extremity is not medically necessary.  Our physician reviewer found that during the last encounter 
on July 17, 2023, left knee pain and pre patellar soft tissue edema were described and no provocative 
maneuvers were done. Also, there were no x-rays of the left knee and no plan of conservative therapy including 
physical therapy or even orthopedic referral are in the records. Therefore, the medical necessity of the 
requested MRI of the left knee has not been documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI of the lower extremity.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2023, to 
February 1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA. NOAs which are received more than 30 days from the timely filing date result in no payment 
being made for the episode of care.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 7, 2023, to 
February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are having trouble with mobility and have been 
through physical therapy. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found during last encounter of May 30, 2023, only 
the lumbar spine symptoms were addressed. Curiously there is an order for MRI lumbar and cervical spine. 
Neuro exam was negative. No red flags. No notes showing physical therapy (PT) has been tried for neck issues. 
Medical necessity of the requested MRI cervical spine has not been demonstrated in the records. 
 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to crown, indirectly fabricated 
(D2952). 
 
You asked the Plan to pre-approve dental services. You say that dental benefits coverage booklet The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
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. Post and core in addition to 
crown, indirectly fabricated (D2952) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post 
and core in addition to crown, indirectly fabricated (D2952).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography cerebral perfusion analyses (CTP) provided 
from February 6, 2023, to February 15, 2023. 
 
You asked the Plan to pay for the CTPs. You say that the records provided support medical necessity. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for the CTPs. Our reviewer says that the 
services were medically necessary. Our physician reviewer found review of the CTA of the brain on February 
6, 2023, revealed a low-density area in the left middle cerebral artery (MCA) highly suspicious for large vessel 
occlusion hence the necessity for the CT perfusion study. This part of the exam was in keeping with the LCD 
requirements for CT perfusion in that the exam is indicated when there is a possibility of large vessel occlusion 
which could be amenable to intervention. These facts are discussed in the report. 
 
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 CTPs have been met. Therefore, we decided that the Plan has to pay for 
computed tomography cerebral perfusion analyses (CTP) provided from February 6, 2023, to February 15, 
2023.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an occupational therapy (OT) visit 
provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for an occupational therapy (OT) visit. You say that you disagree 
with the cost share applied. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for an occupational therapy (OT) visit. This item/service falls 
within the outpatient rehabilitation 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 occupational therapy (OT) visit provided on March 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the daratumumab injection provided on 
February 20, 2023. 
 
You asked the Plan to waive the coinsurance for the daratumumab injection. You say that you received a bill 
from the provider and are submitting for payment. 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 20% 
coinsurance for chemotherapy drugs and the administration of chemotherapy drugs. 
 
You have been asked to pay 20% coinsurance for the daratumumab injection. This item/service falls within the 
chemotherapy drugs and the administration of chemotherapy drugs 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 total you owe is $1,818.40 (medication 
$9,011.18 allowed x 20% = $1,802.24), (admin $80.80 allowed x 20% = $16.16). Therefore, we decided that 
the Plan does not have to waive the coinsurance for the daratumumab injection provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial upper dentures (D5211 and D5213) and the 
partial lower dentures (D5212 and D5214) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental work done as soon as 
possible and you have been waiting 9 months to get your teeth done. The Plan denied your request. The Plan 
says dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve the partial 
upper dentures (D5211 and D5213) and the partial lower dentures (D5212 and D5214) to be provided by an 
out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PT visits provided from May 1, 2023, to May 17, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for PT visits.. You say that you were not aware the provider was out-of-network. 
The Plan denied your request. The Plan says an authorization was not obtained prior to services rendered. 
 
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 PT visits provided from May 1, 2023, to May 17, 
2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on April 24, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you do not 
understand how you owe a copayment and the Plan did not pay towards the claim. 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 $300 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $300 copayment for a magnetic resonance imaging (MRI). 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. The total you owe is $135.06, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on February 20, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on February 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on May 25, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you are unable to afford the 
copayments for the chemotherapy treatments. 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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy. This item/service falls within the Medicare 
Part B Prescription Drugs 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 total you owe is $ $820.35, which is 20% of the allowed amount for chemotherapy 
($4101.77 allowed x 20% = $820.35). Therefore, we decided that the Plan does not have to waive the 
coinsurance for chemotherapy provided on May 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 2, 2023, 
to March 14, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you do not understand why you are 
being charged because you were in the facility for rehabilitation. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $1,960 for a SNF stay ($196 per day x 10 days = $1,960). This item/service falls 
within the SNF care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided 
from March 2, 2023, to March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on March 27, 2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that the MRI 
copayment should have been included as part of the office visit. 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for a magnetic resonance imaging (MRI). 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a magnetic resonance imaging (MRI) provided on March 27, 2023, to March 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic testing and radiology 
services provided on February 2, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic testing and radiology services . You say 
that you feel the services you received should be covered in full by your insurance. 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 $5 
copayment for each Medicare-covered lab service, $30 copayment for each Medicare-covered x-ray and $10-
$325 copayment for each Medicare-covered CT scan. $10 copay for services provided by your primary care 
physician in their office or $325 copay for services performed by a provider other than your primary care 
physician. 
 
You have been asked to pay a total of $325 for outpatient diagnostic testing and radiology services .  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 2, 2023 Lab services $60.02 $5 $5 
February 2, 2023 Chest x-ray $75.50 $30 $25 
February 2, 2023 CT scan $979.70 $325 $295 
TOTAL:    $325 
 
These services fall 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 outpatient diagnostic testing and radiology services 
provided on February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cataract removal procedure to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the cataract removal procedure. You say that the enrollee wants to go to this 
provider. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
cataract removal procedure to be provided by an out-of-network (OON) provider.