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

 
We decided that the Plan does not have to pay for bilateral breast ultrasounds (codes 76641-RT and 76641-LT) 
and screening mammography (code 77067) billed for date of service March 24, 2022. 
 
You asked the Plan to pay for the breast ultrasounds and screening mammography.. You say that you have 
provided medical records to support payment of these services. The Plan denied your request. The Plan says 
these services are not supported by the medical record. 
 
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 76641 is breast ultrasound.  The definition of code 77067 us screening mammography, bilateral, with 
computer-aided detection. 
 
With your appeal request, you provided authorization documents for the ultrasounds and the mammogram as 
well as two distinct procedure notes for these services.  One of the procedure notes specifically addresses 
screening digital bilateral breast mammography with computer-aided detection.  The other procedure note 
specifically addresses bilateral breast ultrasound. We agree that these services were performed.  However, the records show that these services were performed on March 21, 2022.  You billed these services with date of 
service March 24, 2022.  There are no records to support that these services were performed on March 24. 
2022.  Because the date of service billed does not match the date of service in the medical record, these codes 
cannot be supported.  
 
Based on this information, we decided that Medicare rules for coverage of the breast ultrasounds and screening 
mammography. have not been met. Therefore, we decided that the Plan does not have to pay for bilateral breast 
ultrasounds (codes 76641-RT and 76641-LT) and screening mammography (code 77067) billed for date of 
service March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on November 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 genetic testing provided on November 5, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography (75774) provided on September 13, 2021. 
 
You asked the Plan to pay for the angiography (75774). You say that CPT code 75774 was needed separately 
due to non-invasive imaging demonstrating left anterior tibial artery occlusion. You say that this is documented 
in the operative report and the claim should be reprocessed accordingly. The Plan denied your request. The 
Plan says procedure code 75774 is considered inclusive to procedure code 37228. 
 
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 75774 is a column II code to column I code 37228; however, 75774 
was billed with a modifier.  
 
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 angiography (75774). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that an 
angiography would be performed with the intervention. The procedure report does not support the angiography 
as a separate procedure from the intervention performed. 
 
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 angiography (75774) have not been met. Therefore, we decided that the Plan 
does not have to pay for the angiography (75774) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a house ramp. 
 
You asked the Plan to pre-approve a house ramp. You say that you do not agree with the denial and are 
requesting reconsideration for the house ramp. The Plan denied your request. The Plan says the requested item 
is not a covered benefit with Medicare or your Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a house ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 22, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you weren't even in the 
office for five minutes and then you were referred to see someone else. The Plan denied your request. The Plan 
says the copayment applied is 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 $45 
copayment for each Medicare covered visit with a specialist.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth specialist office visit provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for telehealth specialist office visit. You say that since it was 
COVID-19 related it should be free. The Plan denied your request. The Plan says the copayment applied is 
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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist which includes 
telehealth visits.  
 
 
 
 You have been asked to pay $40 copayment for telehealth specialist office visit. Telehealth specialist office 
visits fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 telehealth specialist office visit provided on November 24, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on November 6, 2021. 
 
You asked the Plan to pay for initial hospital care.  The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for initial hospital care provided on November 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you weren't given a 
choice to take an ambulance but were made to. 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 $225 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $225 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 provided on April 12, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
April 26, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that no polyps were 
removed, and you are being billed for something that the doctor said was not done. 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 $290 
copayment for outpatient hospital facility visit. Because you have a history of diverticulosis this procedure is 
not considered a screening but diagnostic in nature and a copayment is applied. 
 
You have been asked to pay a $290 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the Outpatient Hospital 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 the diagnostic colonoscopy provided on April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this was done in a surgical 
center not the hospital so your copayment shouldn't be this much. The Plan denied your request. The Plan says 
the copayment applied is 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 $300 
copayment for surgical services in an outpatient hospital facility.  
 
You have been asked to pay $300 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided 
on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were told you would only 
have to pay $15 copayment since you didn't see your doctor. The Plan denied your request. The Plan says the 
copayment applied is 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 $30 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay $30 copayment for urgent care visit. Urgent care visits fall 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 urgent care visit 
provided on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 27, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, there are no medical records from the treating physician to 
show that the Medicare rules for coverage have been met. Therefore, we decided that the Plan does not have to 
pay for the gene panel testing provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a first visit to a chiropractor and 15 visits for 
chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve a first visit and chiropractic manipulative treatment. You say that 
chiropractic manipulative treatment is medically necessary to help with diagnosis of cervicalgia. The Plan 
denied your request. The Plan says chiropractic manipulative treatment is not medically necessary and there is 
no exam or x-ray to that show subluxation is needed. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic manipulative treatment. 
Our reviewer says that chiropractic manipulative treatment is not medically necessary. Our physician reviewer  
found that the documentation does not support that the enrollee has a neuromuscular condition for which 
manual manipulation is medically reasonable and necessary. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a first visit to a chiropractor and 15 visits for chiropractic 
manipulative treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth office visit provided on April 27, 
2022. 
 
You asked the Plan to waive the copayment for telehealth office visit. You say that since COVID-19 is still an 
issue, telehealth visits should be covered. The Plan denied your request. The Plan says the copayment applied 
is 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 $30 
copayment for each telehealth specialist visit.  
 
You have been asked to pay $30 copayment for telehealth office visit. Telehealth office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 telehealth office visit provided on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 30, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered 
without prior authorization. 
 
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 inpatient hospital services provided on January 30, 
2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary/rest home visit and debridement services 
provided on December 1, 2021. 
 
You asked the Plan to pay for the domiciliary/rest home visit and debridement services. The Plan denied your 
request. The Plan says original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a domiciliary/rest home visit and debridement services 
provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 office visit provided on March 4, 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 procedure code 99053 billed for date of service June 3, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for telehealth mental health visits provided 
from September 1, 2021, to June 1, 2022. 
 
You asked the Plan to waive the copayments for telehealth mental health visits. You say that the Evidence of 
Coverage (EOC) wasn't clear, and you thought you were saving money by not going in person. The Plan denied 
your request. The Plan says the copayments applied are 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 $30 
copayment for Telehealth Services.  
 
You have been asked to pay $930 ($30 x 31 visits) copayment for telehealth mental health visits. Telehealth 
mental health visits fall within the Telehealth 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 copayments for telehealth mental health visits provided from September 1, 2021, to June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular gene panel testing provided on February 
23, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says Medicare denies coverage for all 
cardiovascular risk assessment panels. 
 
The Plan must follow Medicare rules. Medicare rules say that screening tests, with the exception of a few tests, 
are not covered. 
 We looked at the file and Medicare rules. Screening services such as pre-symptomatic genetic tests and 
services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not 
covered. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel 
testing provided on February 23, 2022.