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

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service September 
22, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that this code was denied improperly because a 
separate report was done. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 99291 and no modifiers are allowed for this code pair. 
 
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 93042 
is a column II code to column I code 99291. 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 93042 billed for date of service September 22, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee from August 24, 
2021, to August 26, 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 no request for post-stabilization care was received. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with 
monitoring to a plan facility after the emergency room evaluation on 8/24/2021. There was no documentation 
provided indicating post stabilization care services from 8/ 24/ 2021 to 8/26/ 2021 at the non-Plan facility. The 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service. 
 
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 pay for inpatient services provided to the enrollee from August 24, 2021, to August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 15, 
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 laboratory tests are the responsibility of the dialysis center and are not separately reportable 
by the laboratory. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that You say that you do not have a contract saying that 
these lab services are included in the payment to the dialysis facility. The Plan denied your request. The Plan 
says payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870-26 billed for date of service June 18, 
2021. 
 
You asked the Plan to pay for procedure code 95870-26. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says payment for code 95870 is bundled 
into payment for code 95861 and no modifiers were 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, we have confirmed that code 95870 
is a column II code to column I code 95861. 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 95870-26 billed for date of service June 18, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits beyond the one approved transition visit to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits beyond the one approved transition visit to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits beyond the one approved transition visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4550 billed for date of service December 8, 2021. 
 
You asked the Plan to pay for code A4550. You say that you have provided medical records to support 
payment of this service. The Plan denied your request. The Plan says procedure code A4550 is not covered.  
The Plan gas failed for the other codes billed on this date of service, minus the enrollee's applicable copayment. 
 
The Plan must follow Medicare rules. Medicare rules say that for services billed under the Medicare Physician 
Fee Schedule that have a status indicator of X, these services are statutorily excluded.  No payment is made for 
these services under the Medicare Physician Fee Schedule. Code A4550 has a status indicator of X. Based on 
this information, we decided that Medicare rules for coverage of code A4550 have not been met. Therefore, we 
decided that the Plan does not have to pay for code A4550 billed for date of service December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract saying that these lab 
services are included in the payment to the dialysis facility. The Plan denied your request. The Plan says 
payment for these lab services is bundled into payment made to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  This rule applies regardless of your contract status with the 
ESRD facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 30, 2020, to 
August 5, 2020, at Diagnosis Related Group (DRG) 266. 
 
You asked the Plan to pay for inpatient hospital services at DRG 266. You say that DRG was billed 
appropriately. The Plan denied your request. The Plan says because a diagnosis of J95.1 acute pulmonary 
insufficiency was not present on admission and was not supported by the hospital record, the DRG payment 
was downgraded from DRG 266 to DRG 267. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a diagnosis code of J95.1 acute pulmonary 
insufficiency. 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 inpatient hospital services 
at DRG 266. Our reviewer says that the diagnosis of J95.1 acute pulmonary insufficiency was not supported in 
the medical record. Our physician reviewer found The review indicates that the enrollee was a 69-year-old with 
a significant medical history of coronary artery bypass graft (CABG) in 1998 with redo CABG the same year, 
chronic systolic congestive heart failure, diabetes, chronic kidney disease, and chronic lymphocytic leukemia, 
which was diagnosed in 2018, treated with chemotherapy, and is now in remission. He reported dyspnea with 
exertion and fatigue for over a year. Testing in 2019 showed severe mitral valve regurgitation with posterior 
leaflet prolapse. He was referred for evaluation for minimally invasive mitral valve surgery. He was on 
appropriate guideline directed medical therapy; he was intolerant of beta blocker due to bradycardia and ACE 
inhibitor was stopped due to worsening renal function. He was not frail and ambulated without assistive 
devices status post coronary bypass, presented with increasing dyspnea. He was found to be a suitable 
candidate for minimally invasive mitral valve replacement with the experimental Tendyne device. He was 
taken to the operating room on July 30, 2020, for surgical repair. Following surgery, he was transferred to the 
intensive care unit (ICU) in stable condition. He was followed by pulmonary and cardiology during his hospital 
stay. He remained stable in the ICU for several days and was then able to transfer to the stepdown unit. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 30, 2020, to August 5, 2020, at Diagnosis Related Group 
(DRG) 266.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee has been stable on this medication since 
2016. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan 
says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says 
the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5 mg tablets.  
 Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit received on July 12, 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 this service is not covered when billed by a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit received on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile imaging services provided on November 29, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mobile imaging services. You say that the patient was unable to travel for 
these services and you believe that prior authorization is not required. The Plan denied your request. The Plan 
says unauthorized, non-plan care is not covered. 
 
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. 
 Your organization is not a network provider with the Plan. 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 mobile imaging services provided on November 29, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pay for intraoperative neuromonitoring. You say that the treating surgeon requested 
these services, and they are payable by Medicare. The Plan says that the denial of payment for these services is 
correct, because codes 95861 and 95868 exceed the Medically Unlikely Edit (MUE) values for these codes. 
 
We decided that the Plan has to pay for intraoperative neuromonitoring code 95999.  
 
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. The Plan did not provide any rationale or evidence to justify a denial of code 
95999. This unlisted neurological code was billed to represent train of four (TOF) testing for intraoperative 
neuromonitoring. Therefore, the Plan has not shown that its decision to deny payment for this service is correct 
or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for intraoperative 
neuromonitoring code 95999.  
 
We also decided that the Plan does not have to pay for additional units of intraoperative 
neuromonitoring codes 95861 and 95868. 
 
The Plan follows Medicare rules. Medicare rules state that codes with a medically unlikely edit adjudication 
indicator (MAI) of 3 may rarely exceed the medically unlikely edit (MUE) value of the code when the 
contractor has evidence that excess units were correctly coded. Code 95861 and 95868 both have an MUE 
value of 1, and the Plan has already paid for 1 unit of each code. The Plan was not given sufficient evidence to 
bypass the MUE value for additional units of these codes. Therefore, we decided that the Plan does not have to 
pay for intraoperative neuromonitoring codes 95861 and 95868 beyond what the Plan already paid. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental computed tomography (CT) scan (code D0368) 
you received on October 8, 2021. 
 
You asked the Plan to pay for the dental CT scan. You say that you are not aware of any limitations on covered 
dental procedures. The Plan denied your request. The Plan says dental CT scans are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your dental benefit includes 
coverage only for those dental codes listed in your benefit chart.  It excludes coverage of dental CT scans, 
cephalograms, and magnetic resonance imaging (MRI). 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
computed tomography (CT) scan (code D0368) you received on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on March 6, 2020. 
 
You asked the Plan to pay for the dermatology services. You say that you sent the claim on time, but it was 
rejected. The Plan denied your request. The Plan says you did not file a corrected claim within the appropriate 
time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for the dermatology services was not filed until December 1, 2021. 
This means that more than one calendar year from the date of service had passed before a corrected claim was 
filed. Therefore, we decided that the Plan does not have to pay for dermatology services provided on March 6, 
2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is 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. Medicare rules say that that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that the enrollee is intolerant to statins. The Plan denied 
your request. The Plan says this drug is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexletol.  
 
 
 Benefits for Nexletol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 29, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you feel you were overcharged. 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 $40 
copayment for office visit.  
 
You have been asked to pay a $40 copayment for office visit. office visit falls 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 office visit on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lumbar x-ray provided on December 1, 
2021. We also decided that the Plan does not have to waive the copayment for a magnetic resonance imaging 
(MRI) of the lumbar spine provided on December 14, 2021 
 
You asked the Plan to waive the copayment for an x-ray and an MRI. You say that you paid $40 when you 
went to the providers office. You also say that you are now getting billed for an additional $40 which the 
insurance company told you was for x-ray services. 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 $40 
copayment for in-network outpatient basic radiological services, including x-rays at an outpatient hospital visit. 
The Plan contract also says that enrollees must pay a $100 copayment for in-network advanced imaging, 
including MRIs at an outpatient hospital visit. 
 
You have been asked to pay a $40 copayment for an x-ray on December 1, 2021. An x-ray falls within the 
Outpatient Basic Radiological Services benefit category. You have also been asked to pay a $100 copayment 
for an MRI on December 14, 2021. An MRI falls within the Advanced Imaging 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 a lumbar x-ray provided on December 1, 2021. We also decided that 
the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the lumbar spine 
provided on December 14, 2021