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

 
We decided that the Plan does not have to waive the copayment for X-rays of the chest provided on September 
9, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you were informed that all COVID-19 
related treatment was fully covered. 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 $50 
copayment for X-rays provided at an outpatient hospital.  
 
 
 You have been asked to pay a $50 copayment for the X-rays. Please note that COVID-19 cost share waivers 
ended on May 31, 2021. The X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies 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 X-rays of the chest 
provided on September 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
October 21, 2021, through October 24, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $400 per 
day, for days 1-4 and $0 per day, for days 5-90 for inpatient hospital care.  
 
 
 You have been asked to pay $800 ($400 copayment x 2 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from October 21, 2021, 
through October 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the previous compliance report did not indicate adherence to CPAP therapy. 
 
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have difficulty adhering to use of this device, in part due to a lack of understanding. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services for upper gastrointestinal endoscopic 
procedures (00731) billed for date of service August 4, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the services at issue are inclusive to another billed 
code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 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 anesthesia services. Our reviewer says that 
the billed code 00731 does not meet criteria for reimbursement. Our physician reviewer found that the 
operative report describes anesthesia services to support Gastroscopy with Hemorrhage Control, with start time 
17:00 and end time 17:50. The documentation does not include additional procedures performed on this date of 
service. When multiple anesthesia services are performed with the same anesthesia, the more complex 
procedure would be reported; therefore, CPT 00731 would be inclusive to CPT 00732 which has been 
approved. The modifier does not support reporting two anesthesia procedure codes for same anesthesia service 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. 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 for upper gastrointestinal endoscopic procedures (00731) billed for date 
of service August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99153) provided on August 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an add-on code. 
 
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 99153 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 (99153) provided on August 13, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an angiography of unilateral extremity with radiological supervision 
and interpretation (75710) provided on May 18, 2021. 
 
You asked the Plan to pay for an angiography of unilateral extremity. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the provided 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 CPT Code Manual definition of 
code 75710 is "Angiography, extremity, unilateral, radiological supervision and interpretation." 
 
We asked our coder 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 an angiography of unilateral extremity. Our reviewer says 
that the billed code 75710 meets criteria for reimbursement in this case. Our reviewer found that the report of 
the fistulagram done on May 18, 2021, clearly describes and documents the selective catheterization and 
subsequent angiogram of the brachial artery. The provided documentation satisfies requirements for the billing 
of CPT code 75710. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiography of unilateral extremity have been met. Therefore, we decided 
that the Plan has to pay for an angiography of unilateral extremity with radiological supervision and 
interpretation (75710) provided on May 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation and management service provided on October 
25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that it is the facilities 
responsibility to get proper authorization and the service provided was medically necessary for the enrollee. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider with no 
referral from an in-network provider or an approved authorization. Also, the services rendered was not urgent 
or emergent. 
 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 evaluation and management service provided 
on October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
22, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the staple removal should 
have been included with the laceration repair visit. 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 $30 
copayment for each urgent care center or walk-in clinic visit.  
 
 
 You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the abdomen without 
dye (74181) provided on November 7, 2021. 
 
You asked the Plan to pay for the MRI. You say that the enrollee received multiple exams on this date. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
edit exists between 74183 and 74181. This PTP edit has a modifier indicator of 1, which indicates that 
modifiers associated with this pair are allowed. However, an appropriate NCCI modifier was not billed with 
this PTP code edit. 
 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 74181 
is a column II code to column I code 74183. 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 magnetic resonance imaging (MRI) of the abdomen without dye 
(74181) provided on November 7, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the emergency room visit provided on October 8, 
2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
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. Specifically, the Plan says you must pay a $90 copayment for the emergency 
care service provided. Based upon the Plan contract however, you cannot be asked to pay more than a $0 
copayment for an emergency care visit provided if you are admitted into the hospital for the same condition 
within 24 hours of that visit. You have stated that you were admitted to a different hospital on the same day of 
the emergency care visit provided. The Plan has not submitted information to our organization to support their 
denial regarding this matter. Therefore, we decided that the Plan has to waive the copayment for the emergency 
room visit provided on October 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 30, 
2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that your husband had the same 
procedure done and he did not pay this amount. You would like for this charge to be covered. The Plan denied 
your request. The Plan says the proper copayment was applied for this service. 
 
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 for Medicare-covered surgery or other services provided to you at an outpatient hospital. The total 
amount charged was $185 which is less than the copayment amount of $350. Therefore, the copayment amount 
charged was $185. 
 
  You have been asked to pay a $185 copayment for the outpatient surgery. The outpatient surgery falls within 
the Outpatient Surgery and Other Medical 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 outpatient surgery 
provided on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was ordered by the enrollee's 
treating physician, so services were rendered. The Plan denied your request. The Plan says the rendering and 
referring providers are both out-of-network providers and there was no approved authorization. Also, services 
rendered were not urgent or emergent. 
 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 the laboratory services provided on November 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation and management service provided on 
November 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the facilities staff did not 
get the prior authorization and the physician treated the enrollee out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 evaluation and management service provided 
on November 11, 2021, 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 provided on November 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the physician ordered these services, and 
the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider with no approved authorization. Also, the services rendered was not urgent or emergent. 
  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 the laboratory services provided on November 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Afirma Genomic Sequencing testing provided to the enrollee 
on July 30, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81546 to report Afirma Genomic Sequencing testing. 
 
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 81210 is "BRAF (B-Raf proto-oncogene, 
serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s)." 
 
We find that CPT code 81210 is not supported in the medical record. Specifically, code 81546 should be used 
for this testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Afirma Genomic Sequencing testing 
provided to the enrollee on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of clinical information. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has low back pain with paraspinal point tenderness.  The record does not indicate that the enrollee 
had an injury or has any focal neurological deficits. The record does not indicate that plain films have been 
performed or what conservative treatments have been undertaken. The record does not indicate the occurrence 
of acute injury. The record does not include a neurologic or mental status examination. The requested service is 
not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at 
this time. The elements of the coverage criteria are not satisfied. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and cardiovascular services provided on 
November 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory and cardiovascular services. You say that the services were 
provided to the enrollee and the claim should be paid. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from the enrollee's primary care 
physician. Also, the services rendered was not urgent or emergent. 
 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 the laboratory and cardiovascular services 
provided on November 24, 2021, by an out-of-network (OON) provider.