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

 
We decided that the Plan does not have to pay for an x-ray exam of the chest and x-ray services provided on 
April 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray exam of the chest and x-ray services. You say that you have already 
requested the prior authorization number. You also say that you submitted the claim along with the 
authorization number, but the claim denied for service needing authorization. The Plan denied your request. 
The Plan says the rendering provider was out-of-network with the Plan. The Plan also says that their records do 
not reflect an approved authorization issued for the date of service. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray exam of the chest and x-ray services 
provided on April 7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 3, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that related claim was billed with POS 21 and it 
was paid. The Plan denied your request. The Plan says you billed with an incorrect POS on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the correct Place of Service 
(POS) code on the claim form. POS 21 represents inpatient hospital services. POS 22 represents on-campus 
outpatient hospital. In this case, you billed this service with POS 21, indicating inpatient hospital.  However, 
the claims history shows that this patient was not an inpatient but were in an outpatient observation stay on this 
date of service. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on 
March 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) tracing rendered on February 8, 
2022. 
 
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 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 93005 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 electrocardiogram 
(EKG) tracing rendered on February 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy services (90832) provided on December 22, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the record shows that the provider 
documented a consultation or attempt to consult the enrollees attending/primary physician. Therefore, we 
decided that the Plan has to pay for psychotherapy services (90832) provided on December 22, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 28, 
2022, to February 26, 2022. 
 
You asked the Plan to pay for the SNF care. You say that these are coverable services. The Plan denied your 
request. The Plan says the patient did not meet criteria for SNF coverage on these dates of service. 
 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 the SNF care. Our reviewer says that these 
SNF services were not medically necessary. Our physician reviewer found the enrollee was admitted to the 
SNF on without documented skilled needs.  While the enrollee subsequently tested positive for COVID-19, she 
was noted to be asymptomatic and did not require skilled services. On February 14, 2022, the enrollee was sent 
to an acute care hospital and reportedly stayed there through February 21, 2022.  The enrollee could not have 
received SNF services if she was in the acute care hospital. Upon return to the nursing home on February 21, 
2022, the enrollee was only receiving comfort care while awaiting Hospice. 
  
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from January 28, 2022, to February 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from October 1, 2021, through October 30, 2021. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient skilled nursing facility care 
provided was not medically necessary for the enrollee. 
 
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 the SNF care. Our reviewer says that the 
inpatient skilled nursing facility care provided was not medically necessary. Our physician reviewer found that 
based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have 
documented skilled nursing or skilled therapy needs. Daily skilled services were not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. As a practical matter, the 
enrollees care needs, custodial and intermittent, could have been provided at a lower level of 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from October 1, 2021, through 
October 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on October 22, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 16, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray rendered on October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography services coded 77065 provided 
on March 8, 2022.  
You asked the Plan to pay for the diagnostic mammography services. You say that you disagree with the Plan's 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic mammography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the diagnostic mammography services coded 77065 provided on March 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you only rode in the 
ambulance with your husband, who needed treatment. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 $225 
copayment for each one-way ground ambulance trip.  
 
The file shows that transportation and treatment was also provided due to a positive COVID-19 test. Therefore, 
you have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of 
intraocular lens prosthesis. 
 
You asked the Plan to pre-approve extracapsular cataract removal with insertion of intraocular lens prosthesis. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cataract surgery will be considered medically 
reasonable and necessary when specific criteria are met. 
 
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 extracapsular cataract removal with 
insertion of intraocular lens prosthesis. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the record provided is insufficient to establish the medical necessity and 
reasonableness, as defined by Medicare rules, of placement of an intraocular lens. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracapsular cataract removal with insertion of intraocular lens prosthesis have 
not been met. Therefore, we decided that the Plan does not have to pre-approve extracapsular cataract removal 
with insertion of intraocular lens prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services performed on March 
23, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that the charged amount is too high 
for the services provided. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $350 
copayment per date of service for surgery or services at an outpatient hospital.  
 
You have been asked to pay a $350 copayment for the wound care. The wound care is considered a surgical 
procedure and 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 wound care services performed on March 23, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on March 7, 2022. 
 
You asked the Plan to pay for these services. You say that the enrollee was referred by a network provider. The 
Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for these services by a contract provider. The file does not show that the plan 
provided notice that these services would not be covered. Under Medicare rules, this means these services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services 
rendered on March 7, 2022.  
 
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 waive the deductible for lab tests on April 06, 2022. 
 
You asked the Plan to waive the deductible for lab tests. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $450 deductible which applies to Outpatient diagnostic test and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic test and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to Outpatient diagnostic test and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
lab tests was received on April 6, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for lab tests on April 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided January 31, 2022 
to February 14, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that the services were 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G2067 is not supported in the medical record. Specifically, Medicare requires non-
residential free standing Opium Treatment Program providers to submit claims for this code with Type of Bill 
87x. The claim was submitted with an incorrect Type of Bill. Based on this information, we decided that 
Medicare rules for coverage of the opioid treatment services have not been met.  Therefore, we decided that the Plan does not have to pay for opioid treatment services (G2067) provided 
January 31, 2022 to February 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
February 1, 2022, through February 23, 2022. 
 You asked the Plan to pay for the provided SNF services. You say that you would like these services 
reprocessed and approved for payment. The Plan denied your request. The Plan says rules for SNF care have 
not been met. 
 
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 the provided SNF services. Our reviewer 
says that the SNF care provided was not medically reasonable and necessary. Our physician reviewer found the 
enrollee is an 86-year-old female with a history of hypersensitivity lung disease, hypothyroidism, colon cancer, 
and dementia. From February 1, 2022, through February 18, 2022, there is no evidence that the enrollee needed 
skilled services. The enrollees care needs appear to have been custodial during the dates in question. In 
addition, from February 19, 2022, through February 23, 2022, there is no evidence that the enrollee was at the 
facility in question. 
 
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 provided SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 1, 2022, 
through February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99497) provided February 27, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed 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, the CPT Code Manual definition of code 99497 is Advanced Care Planning. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, CPT 99220 was billed for 
the same date of service. The provided records do not show this is a separate and distinct service. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99497) provided February 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 and 88342 billed for date of service 
March 8, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for code 88341 and 88342 is bundled into payment for 
code 88361. 
 
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 codes 
88341 and 88342 are column II codes to column I code 88361. 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 88341 and 88342 billed for 
date of service March 8, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the request for acupuncture services for neck pain is 
not covered. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 3, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 3, 2022.