Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections with ultrasonic guidance (64445, 64447, 76942) 
provided on July 1, 2019. 
 
You asked the Plan to pay for injections with ultrasonic guidance. You say that these services should be 
covered. The Plan denied your request. The Plan says there are not records for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 64445, 64447, and 76942 are not supported in the medical record. Specifically, no 
medical records for the billed date of service have been submitted. Based on this information, we decided that 
Medicare rules for coverage of injections with ultrasonic guidance have not been met. Therefore, we decided 
that the Plan does not have to pay for injections with ultrasonic guidance (64445, 64447, 76942) provided on 
July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 20, 2020, to February 22, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $300 copayment per day for days 1-2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $600 ($300 x 2 days = $600). An inpatient hospital stay falls within the 
inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider on February 20, 2020, to February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided from June 2, 
2020, to June 4, 2020. 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network 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 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. 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 out of network chiropractic 
services provided from June 2, 2020, to June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on May 18, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on June 
11, 2020. 
 
You asked the Plan to waive the copayment for a spinal canal injection. You say that you disagree with the 
charges because you were only there for 30 minutes. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $325 copayment for a spinal canal injection. A spinal canal injection falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 spinal canal injection provided 
on June 11, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on December 5, 2019. 
 
You asked the Plan to pay for drug test. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this service is correct, because the 
documentation does not support the date of service billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, as a general rule, the billed date of service for 
laboratory testing must be the date the specimen was collected.  
 
We looked at the file and Medicare rules. The specimen for this testing was collected on December 5, 2019. 
The documentation does not show that the circumstances of this testing met any of the exceptions to the 
general rule for billing a date of service for laboratory testing. Based on this information, we decided that 
Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug 
testing provided on December 5, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Leuprolide Acetate injection you 
received on December 9, 2019. 
 
You asked the Plan to waive the coinsurance for the Leuprolide Acetate injection. You say that you have never 
had to pay coinsurance for this drug before. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 drugs.  
 
You have been asked to pay 20% coinsurance for the Leuprolide Acetate. The Leuprolide Acetate injection 
falls within the Medicare Part B 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. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the Leuprolide Acetate injection you received on December 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
had on February 1, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you went to the ER and the staff was 
unprofessional.  You say that you should have your copayment refunded. The Plan denied your request. The 
Plan says you were charged this copayment 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 $225 
copayment for advanced imaging services.  
 
You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging 
services benefit category. This copayment applies regardless of your satisfaction with the services received. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on February 1, 
2020.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. 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. The enrollee was admitted for congestive heart failure. 
Medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of Digoxin coded 80162 provided on May 28, 2020. 
 
You asked the Plan to pay for assay of Digoxin. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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, the CPT Code Manual definition of code 80162 is Digoxin; total. 
 
We find that CPT code 80162 is not supported in the medical record. Specifically, the specimen type collected 
is incorrect for the billed code. Based on this information, we decided that Medicare rules for coverage of assay 
of Digoxin have not been met. Therefore, we decided that the Plan does not have to pay for assay of Digoxin 
coded 80162 provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 4, 2020. 
 
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 procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood specimens. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study 
(95938) continuous intraoperative neurophysiology monitoring, from outside the operating room (G0453) 
needle electromyography (95870) provided January 9, 2020. 
 
You asked the Plan to pay for the intraoperative neurophysiological monitoring. You say that the services 
billed are supported in your records. It seems those reviewing the records do not know how to read them. These 
services were provided and documented. You require review and reprocessing of the claim. The Plan denied 
your request. The Plan says the records do not support the service billed. 
 
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, the documentation submitted did not include documentation of the place of service 22 that was 
billed. Therefore, the validity and accuracy of the claim and modifier -26 cannot be verified.  Based on this 
information, we decided that Medicare rules for coverage of the intraoperative neurophysiological monitoring 
have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency 
somatosensory evoked potential study (95938) continuous intraoperative neurophysiology monitoring, from 
outside the operating room (G0453) needle electromyography (95870) provided January 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (SPECT) 
test you had on July 22, 2020. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that you had a referral for these 
services and you need help with this bill. The Plan denied your request. The Plan says you were charged this 
copayment 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 $325 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $325 copayment for the SPECT test. The SPECT test falls within the diagnostic 
radiology 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 the myocardial 
perfusion imaging (SPECT) test you had on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 30, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 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. 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 out of network physician services provided to the enrollee on 
June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 4, 2019. 
 
You asked the Plan to pay for anesthesia services (00840). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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, the CPT Code Manual definition of code 00840 is Anesthesia for intraperitoneal procedures in 
lower abdomen including laparoscopy; not otherwise specified. 
 
We find that CPT code 00840 is not supported in the medical record. Specifically, records supporting the 
service were requested but not submitted. Based on this information, we decided that Medicare rules for 
coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone consult (99442) provided on April 16, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the telephone consult. You say that payment request as medical necessity. Please 
kindly review closely and reconsider payment. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being 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 has network providers 
available who can provide 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 telephone consult (99442) provided on April 
16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88341, 88305, 88342) provided on 
June 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 services (88341, 88305, 88342) 
provided on June 16, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. You say that you would like reconsideration 
because the wheelchair is medically necessary. The Plan denied your request. The Plan says Medicare does not 
cover durable medical equipment (DME) in an SNF based on statutory definition of DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider an SNF or a hospital to be a home.  
 
Records show that the wheelchair and accessories is being requested for use in an SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from January 31, 
2020, to February 5, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes. 
 
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, the CPT Code Manual definition of code S9500 is Home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.  
 
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from January 31, 2020, to 
February 5, 2020.