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

 
We decided that the Plan does not have to pay for the sclerotherapy rendered on June 7, 2021. 
 
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 the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 49185 (sclerotherapy of a fluid collection) and 47536 
(exchange of biliary drainage catheter). Code 49185 is a column II code with a modifier indicator of 1 when 
billed with column I code 47536. Code 49185 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the sclerotherapy rendered on June 7, 
2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 19, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you never went to the ER, you just 
had an ultrasound. 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 $120 
copayment for emergency room services.  
 
Medical records confirm that you were seen in the ER on June 19, 2021, with complaints of leg swelling. The 
records show that you had a large amount of bleeding after hitting your leg on the car door while getting out.  
Paramedics were called to the scene, but you declined to be taken to the hospital by ambulance.  Instead, you 
went to the hospital by private care. You were evaluated in the ER for this bleeding. You have been asked to 
pay a $120 copayment for the ER visit. 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 
emergency room (ER) visit you had on June 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81227, 81230, 81240, 81241, 81291, 81355, 
81479) provided May 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled procedure codes were billed for a single panel in 
this case. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81227, 81230, 81240, 
81241, 81291, 81355, 81479) provided May 12, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, pelvis; without contrast material (CPT Code 72192).
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your
request. The Plan says that the service is not 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 the CT scan. Our physician reviewer
found the ultrasound did not yield good visualization and therefore, the CT is indicated.
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 CT scan have been met. Therefore, we decided that the Plan has to preapprove
CT, pelvis; without contrast material (CPT Code 72192).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound scanning of blood flow 
(outside the brain) on both sides of head and neck (93880) and an ultrasound study of arteries of both arms and 
legs (93923) performed by an in-network hospital on June 15, 2021. 
 
You asked the Plan to waive the deductible for arterial ultrasounds. You say that you have been receiving the 
same tests since 2018 after carotid artery surgery and you have never had to pay for the procedures. You want 
the Plan to pay 100% of the charges. The Plan denied your request. The Plan says the services at issue are 
covered benefits; however, you had not yet met your deductible at the time of service. The Plan says the cost-
share was correctly applied to the deductible. 
 
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 which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
 The arterial ultrasounds you asked the Plan to waive the deductible for fall within the benefit category 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible which applies to Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies. This cost-sharing is a contractual obligation that had not been met at 
the time the arterial ultrasounds were received on June 15, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for an ultrasound scanning of blood flow (outside the brain) on both sides of head 
and neck (93880) and an ultrasound study of arteries of both arms and legs (93923) performed by an in-
network hospital on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 23, 
2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible 
for payment when billed with this code pair. The claim provided does not show that the code at issue was billed 
with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage 
of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5299) purchased from the store on March 9, 2020.
You asked the Plan to pay for hearing aids. You say that hearing aids were less expensive at the store than the Plan provider. The Plan denied your request. The Plan says hearing aids are only covered when purchased from the Plans specific provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plans specific provider. We looked at the file and the Plan's rules. The hearing aids at issue were not purchased from the Plan provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5299) purchased from the store on March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
received on April 28, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not feel as though you should 
pay this copayment because the result of the CT scan did not produce a satisfactory image. 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 $200 
copayment for CT scans.  
 
 You have been asked to pay a $200 copayment for the CT scan. This copayment applies regardless of the 
outcome of the test. 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 received on April 28, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on April 6, 2021. 
 
You asked the Plan to pay for lab test. You say that both insurance plans have said that the other was primary, 
and you need this bill to be taken care of. The Plan denied your request. The Plan says that the denial of 
payment for this service is correct, because this Plan is your Secondary Payer so is not responsible for payment. 
 
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 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 not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not met its obligation with regards to coordination of benefits. 
Specifically, although the Plan contacted your primary insurance carrier, they did not submit any evidence that 
they have sent the bill for this claim to your primary insurer, directed the provider to send a bill to your primary 
insurer, or paid for the service and submitted the bill to the primary insurer for reimbursement. Therefore, the 
Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pay for laboratory testing provided on April 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on April 16, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the claim was denied inappropriately 
and should be reprocessed for payment. The Plan denied your request. The Plan says the diagnosis code of 
Z13.9 represents an encounter for screening. The Plan says that routine services are not covered in an 
emergency room setting. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does not meet prudent layperson criteria for emergency care. A prudent layperson would not reasonably expect the absence of immediate medical care to seriously jeopardize their health in this 
case. Therefore, we decided that the Plan does not have to pay for emergency room services provided on April 
16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81291-XS, 81401-XS, 
81403-XS, 81404-XS, 81405-XS, 81406-XS, 81407-XS, 81408-XS, 81479, 81439) provided to the enrollee on 
October 16, 2020. 

 You asked the Plan to pay for the laboratory services. You say that they corrected the place of service to 12 and 
submitted as a corrected claim. The Plan denied your request. The Plan says the Medicare rules have not been 
met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Medicare denies 
coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented 
cardiovascular disease. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, 
and triglyceride every 5 years, as cardiovascular screening testing. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (CPT code(s): 81291-XS, 81401-XS, 81403-XS, 81404-XS, 81405-XS, 
81406-XS, 81407-XS, 81408-XS, 81479, 81439) provided to the enrollee on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing 
radiographic images (D0274), provided on April 13, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and bitewings. You say that the services were 
medically necessary. The Plan denied your request. The Plan says you obtained these services out of network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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. Specifically, you received these services out of network. This means 
they are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and bitewing radiographic images (D0274), provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from November 29, 
2019, through December 12, 2019, billed with a principal diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the 
inpatient care as billed. The Plan denied your request. The Plan says the billed principal diagnosis code is not 
supported by the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 inpatient hospital care 
as billed. Our reviewer says that the medical records do not support the principal diagnosis as billed. Our 
physician reviewer found that the review indicates that the documentation supported an admission for 
Pneumonia due to Escherichia coli. From the information that was received, documentation was 
inconsistent/unclear regarding a diagnosis of Sepsis. While Systemic Inflammatory Response Syndrome 
(SIRS) criteria may indicate clinical response to non-specific insult, infectious/non-infectious, there was no 
evidence of a systemic, life-threatening organ dysfunction due to a dysregulated host response to infection, 
defining sepsis. White blood cell count was noted to be elevated but there was no evidence of a dysregulated 
host response to infection. The review has determined that the documentation did not support the inpatient 
hospital care billed with a principal diagnosis code A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from November 29, 2019, through December 12, 2019, billed with a 
principal diagnosis code A41.9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76376) provided on June 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 76376 is a column II code to column I code 78226. 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 the services (76376) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment of $250 and the apply the correct coinsurance of $146.52 for the injection services of diagnostic or therapeutic substances (62323) provided March 11, 2020.
You asked the Plan to waive the copayment of $250 and the apply the correct coinsurance of $146.52 for the injection services. You say that you feel that this copay should be waived or changed. It was a 30-minute visit and it was for an injection. You feel that this copay is too high and you are on a fixed income. The Plan denied your request. The Plan says that the $250 outpatient procedures and services copayment applies.
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 enrollees must pay 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.
The Plan says you must pay $250 per day for outpatient procedures and services. Based on the Plan contract, however, you cannot be asked to pay more than 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. The provider billed $1148. The plan allowed $732.61. 20% of $732.61 = $146.52 Therefore the correct cost share is $146.52 for the injection services. Therefore, we decided that the Plan has to waive the copayment of $250 and the apply the correct coinsurance of $146.52 for the injection services of diagnostic or therapeutic substances (62323) provided March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additions to the prosthesis identified with codes 
L5828, L5845, L5848, and L5856. 
 
You asked the Plan to pre-approve the additions to the prosthesis identified with codes L5828, L5845, L5848, 
and L5856. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are only covered for certain 
indications. 
 
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 additions to the prosthesis identified 
with codes L5828, L5845, L5848, and L5856. Our reviewer says that the documentation does not support that 
the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee had a left 
transfemoral amputation. The documentation shows that the enrollee participates in gardening, weeding, 
planting. The requested items exceed the enrollee's medical need as the physician documentation does not 
reveal extenuating factors that indicate the enrollee is unable to meet their functional needs with a mechanical 
K3 knee.  
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 additions to the prosthesis identified with codes L5828, L5845, L5848, and 
L5856 have not been met. Therefore, we decided that the Plan does not have to pre-approve the additions to the 
prosthesis identified with codes L5828, L5845, L5848, and L5856.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the portable x-ray transportation services rendered on June 
11, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code R0070 (transportation of portable x-ray 
equipment) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does 
not have to pay for the portable x-ray transportation services rendered on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin based composites (D2391 and D2332), provided on 
June 6, 2021. 
 
You asked the Plan to pay for the resin based composites. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted your Plan's benefit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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. Specifically, records indicate you have already received these services. 
This means the benefit has been exhausted. 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for the resin based composites (D2391 and D2332), 
provided on June 6, 2021.