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

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0999) provided on June 
28, 2023. 
 
  You asked the Plan to pay for the paramedic intercept services. You say that you say that there was only one 
ambulance, and you already paid the $250 copay. You also say that you would like to know why you are being 
billed another $200 for the same day. The Plan denied your request. The Plan says no payment can be made as 
paramedic intercept is not covered. 
 
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 the 
paramedic intercept services (A0999) provided on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve blocks and 
injections (01992) provided on June 1, 2023. 
 
  You asked the Plan to pay for the anesthesia. You say that authorization for anesthesia services have not 
previously been required, and the referral for the procedure generally extends to the anesthesia provider as 
well. You also say that you would like this claim to be reconsidered for payment. The Plan denied your request. 
The Plan says this claim processed and denied correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has reached out 
to the provider and told them to submit the claim to the primary insurance. The Plan also advised the provider 
that once the claim is submitted to the primary insurance company and the primary Explanation of Benefits 
(EOB) is received, they can then resend the claim to the secondary insurance company. As the secondary 
insurer, the Plan cannot be held responsible for the anesthesia until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the anesthesia for diagnostic or 
therapeutic nerve blocks and injections (01992) provided on June 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with bupivacaine provided on June 5, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine provided on June 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services on May 16, 2023. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you were told your 
copayment was $10 at the time of the service. 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay $35 copayment for physical therapy services. 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 
physical therapy services on May 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74230, 72020, 70100, and 
70310 billed on February 24, 2022.  
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they were medically necessary and are supported in the documentation. The Plan denied your 
request. The Plan says the radiology services are denied because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS. 
 
We looked at the file and Medicare rules. Documentation provided shows code 74230 was performed in a 
mobile unit setting with the use of fluoroscopy. Therefore, this service is not covered and is excluded under the 
portable x-ray provision. Codes 72020, 70100, and 70310 were billed with POS 11, indicating an office setting. 
However, documentation shows the radiology services were performed in a mobile setting. There is no 
evidence the services were provided in an office setting. Based on this information, we decided that Medicare 
rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not 
have to pay for the radiology services coded as 74230, 72020, 70100, and 70310 billed on February 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq, a self-administered drug. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the requested drug is medically 
necessary. 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 pre-approve Myrbetriq, a self-
administered drug.  
 
Benefits for a self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232) 
provided on February 2, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the subsequent hospital inpatient or observation care. You say that you would 
like the medical records to be checked and the claim to be considered for payment, as the services were 
provided with good intention. The Plan denied your request. The Plan says the provider that performed these 
services is not within the Plan's network, and the services were not authorized by the Plan. The Plan also says 
that the medical records provided for date of service, February 2, 2023, do not reveal any medically urgent or 
emergent needed care. 
 
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 subsequent hospital inpatient or observation 
care (99232) provided on February 2, 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 OmniGraf Panel (81479) provided on January 6, 2023. 
 
You asked the Plan to pay for the OmniGraf Panel. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this panel is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 OmniGraf Panel have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the OmniGraf Panel (81479) provided on January 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Health Physical Therapy x7. 
 You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
enrollee was previously approved visits to teach a home exercise program and the records suggest that 
continuing this exercise program should help maintain level of function or improve further. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records do 
not show that 7 additional home health PT visits are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Home Health Physical Therapy x7.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 17, 
2023. 
 You asked the Plan to pay for procedure code 70480. You say that 70480 should be paid as billed because the 
enrollee had multiple exams on the same date of service. The Plan denied your request. The Plan says payment 
for code 70480 is bundled into payment for code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 procedure code 70480 billed for date of service July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on March 22, 2023, to 
May 23, 2023. 
 
You asked the Plan to waive the copayment for injections. You say that you disagree with the cost share 
applied as you did not receive surgical procedure in a sterile environment. 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 $295 
copayment for outpatient hospital services. 
 
You have been asked to pay a $295 copayment for injections. This item/service falls within the outpatient 
hospital 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. You have been asked to pay a total of $590 for injections performed at an outpatient hospital 
facility ($295 per visit x 2 visits = $590). Therefore, we decided that the Plan does not have to waive the 
copayment for injections provided on March 22, 2023, to May 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an out-of-network 
provider from January 4, 2021, to February 2, 2021. 
 You asked the Plan to pay for the home health services. You say that the Plan should be paying the proper 
amount. The Plan denied your request. The Plan says the denial of payment of correct because the Plan is the 
secondary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Specifically, 
the Plan called the provider multiple times to provide an Explanation of Benefits (EOB) for the dates of 
service. As the secondary insurer, the Plan cannot be held responsible for the home health services until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for the home health services provided by an out-of-network provider from January 4, 2021, to February 2, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Itraconazole capsules. 
 
You asked the Plan to pre-approve the medication. You say that you would like the Plan to reconsider their 
denial. 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 pre-approve Itraconazole capsules.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from June 17, 2023, to July 16, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the services should be covered under the 
Medicare Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for continued 
SNF stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the continued skilled nursing facility (SNF) care provided from June 17, 2023, to July 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the injection services provided on June 27, 
2023. 
 
You asked the Plan to reduce the copayment for the injection services. You say that you were told that you 
might have a $20 copayment for this service. 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 $400 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $400 copayment for the injection services. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the injection services provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) provided on June 21, 2023, provided 
by the opt-out provider. 
 
You asked the Plan to pay for the outpatient service. You say that you were advised by a Plan representative 
that this provider is indeed a covered provider under this plan. You also say that payment should go directly to 
you since you already paid the facility. The Plan denied your request. The Plan says that payment cannot be 
made to a provider that has opted out of Medicare.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. The file shows that you signed a Medicare Opt-Out Agreement 
indicating that you agree to not submit receipts, bills or other information to Medicare to seek reimbursement.  Therefore, we decided that the Plan does not have to pay for the office visit (99205) provided on June 21, 2023, 
provided by the opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections performed with a specialist 
provided on July 10, 2023. 
 
You asked the Plan to waive the copayment for injections performed with a specialist. You say that you were 
advised the visit would be covered 100%. 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 $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for injections performed with a specialist. This item/service falls 
within the 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 total you owe is $11.39, which is less than the standard copayment for 
injections performed with a specialist. Therefore, we decided that the Plan does not have to waive the 
copayment for injections performed with a specialist provided on July 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan, of the abdomen; 
with contrast material(s) (74160). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
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 pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that no clinical biochemical or 
imaging studies show the medical necessity of the requested CT scan of the abdomen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan, of the abdomen; with contrast material(s) (74160).