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

 
We decided that the Plan does not have to waive the cost share for the dialysis services provided from March 2, 
2020, to March 30, 2020. 
 
You asked the Plan to waive the cost share for the dialysis services. You say that the provider is billing your 
insurance company for services and then balance billing you the remainder. 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 20% 
coinsurance for covered services for Services to Treat Kidney Disease.  
 
You have been asked to pay $776.64 which is a 20% coinsurance for the dialysis services ($3883.20 is the 
allowed amount for twelve visits x 20% coinsurance = $776.64). Dialysis services fall within the Services to 
Treat Kidney Disease 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 cost share for the dialysis services 
provided from March 2, 2020, to March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital clinic visit provided on 
March 24, 2022 
 
You asked the Plan to waive the copayment for outpatient hospital clinic visit. You say that you were unaware 
that this copayment had changed, and therefore want it waived. The Plan denied your request. The Plan says 
the copayment applied was correct. 
 
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 $235 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $235 copayment for outpatient hospital clinic visit. Outpatient hospital clinic 
visit falls within the Outpatient Hospital Observation for In-Network Medicare-Covered 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 outpatient hospital clinic visit provided on 
March 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound (procedure codes 37252, 37253) 
provided to the enrollee on December 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested service codes are not substantiated by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37252: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure) 
 
 CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is no specific mention of 
intravascular ultrasound in the procedure report of 12/16/21. Absent such specific mention in the technique of 
the procedure reimbursement should not be made. 
 
We looked at this coder'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 pay for intravascular ultrasound (procedure codes 37252, 37253) provided to the enrollee on December 
16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy provided to the enrollee on February 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 31630: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial 
dilation or closed reduction of fracture 
 
CPT 31636: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of 
bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus 
 
 CPT 31641: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor 
or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee has lung cancer 
obstructing a central airway. The progress notes during the recent hospitalization indicate displacement of a 
previously placed stent and intent to replace it via rigid bronchoscopy. But the records do not include a 
procedure note or other documentation that the procedure was performed, and its outcome. 
 
We looked at this coder'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 pay for bronchoscopy provided to the enrollee on February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 17, 
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 March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 at-home test (U0002) provided on March 23, 
2022. 
 
You asked the Plan to pay for a COVID-19 at-home test. You say that the item at issue was a necessity for you. 
The Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a COVID-
19 at-home test is an OTC item. Therefore, we decided that the Plan does not have to pay for a COVID-19 at-
home test (U0002) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office or other outpatient visit provided 
on January 11, 2022. 
 
You asked the Plan to waive the deductible for an office or other outpatient visit. You say that you did not 
know the provider of the services at issue was out-of-network. The Plan denied your request. The Plan says the 
correct cost-sharing was applied. 
 
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 $1,000 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,000 deductible which applies to physician/practitioner 
services, including doctor's office visits, when obtained from an out-of-network provider. This cost sharing is a 
contractual obligation that had not been met at the time an office or other outpatient visit was received on 
January 11, 2022. Therefore, we decided that the Plan does not have to waive the deductible for an office or 
other outpatient visit provided on January 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to care for yourself. The Plan denied 
your request. The Plan says that the services you need can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a tibial fracture after a fall, urinary tract infection, and pneumonia. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you already paid for an 
ambulance trip to the ER but are being charged for a second time for another ambulance trip. The Plan denied 
your request. The Plan says you were charged this cost sharing 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 $290 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $290 for these 
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 the ambulance 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 February 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the services 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 February 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the office visit, physical therapy, therapeutic 
injection, and Part B drugs provided on March 31, 2022, and April 4, 2022. 
 
  You asked the Plan to reduce the cost for the office visit, physical therapy, therapeutic injection and Part B 
drugs. You say that you were told this was all covered by your health insurance and your copay is only $30. 
You say that you can pay this share for each visit. The Plan denied your request. The Plan says the claims 
processed correctly. 
 
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 $400 deductible which applies to Part B drugs. Your contract with the 
Plan says that you must pay 20% coinsurance for each Medicare-covered Part B drug, a $30 copayment for 
each Medicare-covered physical therapy visit and a $15 copayment for services obtained from a primary care 
provider. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Medicare 
Part B Prescription Drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $400 deductible which applies to Medicare Part B drugs received from a physician. This cost sharing is a 
contractual obligation that had not been met at the time the Part B drugs were received on April 4, 2022. 
Therefore, $360.44 has been applied to meet your deductible. 
 
Since you have met your $400 deductible, you have also been asked to pay a total of $204.31 for the office 
visit, physical therapy, therapeutic injection, and Part B drugs. The total amount you have been asked to pay is 
$574.75 ($360.44 + $204.31 = $574.75). 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
03/31/2022 Office Visit $89.30 $15 copayment $15 copayment 
03/31/2022 Physical Therapy $53.88 $30 copayment $30 copayment 
04/04/2022 Therapeutic Injection $45.04 $15 copayment $15 copayment 
04/04/2022 Physical Therapy $126.79 $30 copayment $30 copayment 
04/04/2022 Part B Drugs $571.54 20% $114.31 
TOTAL:    $204.31 
 
The office visit and therapeutic injection fall within the Physician/Practitioner Services, Including Doctors 
Office Visits benefit category. Physical therapy services fall within the Outpatient Rehabilitation Services 
benefit category. The Part B drugs fall within the Medicare Part B Prescription Drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the cost for the office visit, physical therapy, therapeutic injection, and Part B 
drugs provided on March 31, 2022, and April 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 provided records report no acutely unstable medical conditions which appear to 
require a physicians inpatient hospital level evaluation three or more times per week. You do require physical 
therapy and occupational therapy services, but the medical records provided do not clarify why you require an 
intensive inpatient rehabilitation therapy program. The medical records do not clarify that treatment at the 
skilled nursing facility level is not appropriate in this case. Given the chronic nature of your decline, the slower 
pace and longer duration of treatment in a skilled nursing facility may be more suited to your needs than 
acute/short term rehab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 February 14, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service March 22, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 24, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 26, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 laboratory services provided on January 26, 2022 
by an out-of-network (OON) provider.