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

 
We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study 
services coded 95938, the neuromuscular junction testing services coded 95937, and the needle 
electromyography services coded 95861 provided on June 17, 2020. 
 
You asked the Plan to pay for the short-latency somatosensory evoked potential study services, the 
neuromuscular junction testing services, and the needle electromyography services. 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 
payable. 
 
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 95938, 95937, and 95861 are not supported in the medical record. Specifically, the 
billed place of service, 15 is not supported. The documentation supports that the enrollee was inpatient at the 
time services were provided. In addition, these services are not payable in the facility setting. Based on this 
information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential 
study services, the neuromuscular junction testing services, and the needle electromyography services have not 
 
 
been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked 
potential study services coded 95938, the neuromuscular junction testing services coded 95937, and the needle 
electromyography services coded 95861 provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77061) provided on June 24, 
2020. 
 
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 77061 has a status 
indicator of I and 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. 
 
We find that CPT code 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77061 has a status indicator of I. This means that CPT code 77061 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have 
not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77061) 
provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing and office services 
provided on July 1, 2020. 
You asked the Plan to waive the copayment for the services. You say that you had back surgery in January of 
2020 and you are still under the care of the provider and you have been released from their care or follow-ups. 
You state all of your follow-up appointments have been covered except this one. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2020 EOC benefits. The rules say a plan must 
disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles 
and coinsurance). Review of the file show that you received diagnostic testing and office services provided on 
July 1, 2020. You are asked to pay a $30 copayment for the services. The 2020 EOC clear ly states, if you 
receive services from a specialist and get more than one covered service during the Revised May 2015 
Proprietary single visit, and your plan includes copays only. You will pay the highest single copay for all 
services received. The EOC also states for specialist services there is a $30 copay. 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 diagnostic testing and office services provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from August 18, 2020, to September 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
from August 18, 2020, to September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient 
hospital facility on January 23, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were advised there was no 
copayment for lab tests. 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 $15 
copayment for lab services at an outpatient hospital facility.  
 
You have been asked to pay a $15 copayment for the lab services. 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 lab services you received at an outpatient hospital facility on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went in for a routine exam, not 
a medical eye exam. You say that you shouldn't be responsible for the copayment. The Plan denied your 
request. The Plan says the copayment applied 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 exams to diagnose and treat diseases and conditions of the eye. 
 
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" 
benefit category. The records show that this provider is not eligible to bill a routine eye exam; therefore, this 
was covered as a medical eye exam. 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 eye exam 
provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for arthrocentesis provided on July 3, 2020. 
 
You asked the Plan to waive the deductible for arthrocentesis. You say that you disagree with the charges 
beyond the $25 copayment. 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. Your 
contract with the Plan says that there is a $500 deductible for outpatient surgery, including services provided at 
hospital facilities and ambulatory surgical centers.  
 
You received arthrocentesis on July 3, 2020. The record shows that you had only paid $8.28 toward the $500 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $45.01.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time arthrocentesis was received on July 3, 2020. Therefore, 
we decided that the Plan does not have to waive the deductible for arthrocentesis provided on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on August 28, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received due to the quality of care. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to 
its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and 
coinsurance). Review of the file show that you received diagnostic testing and specialist services on August 28, 
2020. You are asked to pay a $10 copayment for the testing and a $35 copayment for the specialist office 
services. Your EOC states that enrollees must pay a $35 copayment for each specialist visit and a $10 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). 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 services provided on August 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was 
pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be 
made for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as 
applicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be paid. The 
blended rate amount will otherwise apply. Providers report the A0428 (BLS) HCPCS code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the 
appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the paramedic intercept service provided on 
July 9, 2020. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the paramedic intercept service 
provided is not payable as the provider does not have a contract with the ambulance company that provided the 
transport. 
 
The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to issue reimbursement for 
the paramedic intercept service provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L4-S1 Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of lumbar stenosis with radiculopathy has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure remains experimental for the treatment of degenerative back pain. More research is needed to sh 
safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an L4-S1 Intracept procedure for the enrollee.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy provided on August 13, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this should be processed as a 
preventative service. The Plan denied your request. The Plan says that the claims were processed correctly and 
you are being charged the correct amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records. Without medical records we cannot 
determine whether the colonoscopy was diagnostic or preventative. Therefore, we decided that the Plan has to 
waive the copayment for a colonoscopy provided on August 13, 2020.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a GeneSight Psychotropic gene panel (81479) provided on 
June 12, 2020. 
 
You asked the Plan to pay for a GeneSight Psychotropic gene panel. You say that this was medically necessary. 
The Plan denied your request. The Plan says the enrollee did not have MDD. 
 
The Plan must follow Medicare rules. Medicare rules say that that GeneSight testing may only be ordered for 
patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe 
depression. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee was 
diagnosed with major depressive disorder. Based on this information, we decided that Medicare rules for 
coverage of a GeneSight Psychotropic gene panel have not been met. Therefore, we decided that the Plan does 
not have to pay for a GeneSight Psychotropic gene panel (81479) provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory services. 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 laboratory services provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe 
gingival inflammation - full mouth, after oral evaluation (D4346) . 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit under the 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. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve scaling in presence of 
generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346) .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic laboratory testing provided on 
April 16, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you are appealing your 
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file show that you received diagnostic laboratory 
testing on April 16, 2020. You are asked to pay a $5 copayment for the lab services. Your EOC states that 
enrollees must pay a $5 copayment for diagnostic lab service sand diagnostic procedures and tests (per day, per 
facility). 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 diagnostic laboratory testing provided on April 
16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on May 20, 2020. 
 
You asked the Plan to pay for the services. 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on May 
20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for treatment of a subdural hematoma after a fall 4 weeks prior. Medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this patient 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 IRF admission and services.