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

 
We decided that the Plan does not have to pay for the medical services provided on May 24, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. 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. 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 medical services provided on May 24, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on March 13, 
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 this was not coded correctly. 
 
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 71045 is a column II code to column I code 74022. 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 imaging services 
provided to the enrollee on March 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 36465) provided to the 
enrollee on January 12, 2022. 
 
You asked the Plan to pay for the services. You say that payment should be made on this claim. The Plan 
denied your request. The Plan says an appropriate modifier was not billed on the claim to indicate the code 
36465-RT as a staged or related surgical procedure done during the postoperative period to the 10-day global 
period of the surgical procedure performed. 
 
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 36465 is "Injection of non-compounded foam sclerosant 
with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance 
and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous 
vein)." 
 
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 documentation describes 
injection of non-compounded foam sclerosant with ultrasound compression maneuvers was performed in the 
global period of another procedure stab phlebectomy of varicose veins which includes a 10-day post-op 
period. In this case, CPT 36465 would not be reported separately, as this procedure was performed during the post-op period, and an unrelated service is not supported. 
 
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 injection services (procedure code 36465) provided to the enrollee on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 10, 
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 denied codes cannot be verified. 
 
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  is "CPT 36140: 
 
Introduction of needle or intracatheter, upper or lower extremity artery 
 CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 36246: 
 
Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family 
 
CPT 37233: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 37233, the 
procedure report does not include of additional vessel, and therefore cannot be verified. The femoral/popliteal 
territory lower extremity is considered a single vessel. In terms of CPT 75710, this code cannot be verified in 
the records. In terms of CPT 75625, the operative report does not include documentation of radiological 
supervision and interpretation of abdominal aortography by serialography. In terms of CPT 36245 and CPT 
36247, these procedures not supported in the records as a separate and distinct procedure. The procedure report 
does not support CPT 36246, CPT 36140, and CPT 75710 as separate and distinct procedures from CPT 37225 
- open or percutaneous endovascular revascularization of a unilateral femoral or popliteal artery, with 
atherectomy, including angioplasty. The use of modifier 59 on these codes is not supported. 
 
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 surgical services provided to the enrollee on January 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services 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 rendering provider is not participating. 
 
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 imaging services provided to the enrollee on 
December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee 
on January 2, 2022. 
 
You asked the Plan to pay for the services. You say that this was needed after a fall at home. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that the ambulance transport provided on 1/2/22 was the only way to safely transport this 
enrollee. Other means of transport were not contraindicated. The enrollee did not need the expertise, services 
and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. 
 
 
 
 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 non-emergent ambulance transport provided to the enrollee on January 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee from January 
14, 2022 and January 15, 2022. 
 
You asked the Plan to pay for the services. You say that this code is appropriately modified as a significant, 
separately identifiable evaluation and management service. The Plan denied your request. The Plan says the 
payment for this service is included in the fee for the procedure. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
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 documentation describes intubation was performed on January 14, 2022, 
bronchoscopy was performed on January 15, 2022, and critical care service performed on January 14, 2022. In 
this case, medical record does not include enough information to verify, intubation and critical care services are 
separate services, emergency or scheduled intubation determines if critical care services are appropriate to 
report separately. 
 
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 critical care services provided to the enrollee from January 14, 2022 and January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on November 
29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
  
 
 
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. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided to the enrollee on November 29, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for ultrasonic guidance for a trigger point injection provided to the enrollee 
on June 7, 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 that the clinical value and effectiveness of ultrasonic guidance for the needle placement of 
superficial trigger point injections have not been demonstrated to improve outcomes or efficacy in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the use of ultrasound guidance is appropriate in this case in order to ensure the injected medication is 
actually in the muscle rather than along the fascia or deep to the muscle. This is an appropriate use of this 
technology. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
ultrasonic guidance for a trigger point injection provided to the enrollee on June 7, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services received on January 6, 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 rendering provider opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services received on January 6, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 8, 2021, to 
August 10, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the admission diagnosis is due to an altered mental state (R41.82). 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the clinical documentation supports that at the time of inpatient admission, the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. The enrollee was very uncooperative at the time of admission and 
had to be transported in four point restraints to the medical unit. The initial impression included polysubstance 
overdose, schizoaffective disorder, and acute encephalopathy. At the time of admission, it is documented that 
the enrollee was in restraints, was lethargic, and was oriented. Restraints were continued. A psychiatry 
consultation was obtained on 8/9/21 because the enrollee reported taking an overdose of Zydis after drinking 
gin and smoking crack cocaine. The enrollee was deemed to be safe for discharge to the community by 
psychiatry. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital care provided to the enrollee from August 8, 2021, to August 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided to the enrollee on December 7, 
2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services and is not 
separately reimbursable. 
 
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 testing provided to the enrollee on December 7, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for CT scan of the chest and interpretation of the 3D 
image. We decided that the Plan does not have to waive the copayment for CT scan of the abdomen and pelvis.  
 
You asked the Plan to waive the copayment for CT scan of the chest and interpretation of the 3D image. You 
say that you shouldn't be charged for out of network provider. The Plan says that the copayment applied is 
correct. 
 
We decided that the Plan has to waive the copayment for CT scan of the chest and interpretation of the 
3D image.  
 
The Plan follows Medicare rules. Medicare rules say that if multiple tests of the same type (for example, CT 
scan of the head and CT scan of the chest) are performed in the same day one copayment will apply 
 
Therefore, we decided that the Plan has to waive the copayment for CT scan of the chest and interpretation of 
the 3D image.  
 
We also decided that the Plan does not have to waive the copayment for CT scan of the abdomen and 
pelvis. 
 
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 $95 
copayment for CT scan of the abdomen and pelvis. Therefore, we decided that the Plan does not have to waive 
the copayment for CT scan of the abdomen and pelvis. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided to the enrollee on 
October 29, 2020. 
 
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 should be billed to Original Medicare. 
 
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 subsequent nursing facility care provided to the enrollee on 
October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Bimatoprost injection provided on 
January 28, 2022. 
 
You asked the Plan to waive the coinsurance for the Bimatoprost injection. You say that it was not clear you 
would have to pay a high copayment like this when you signed up for the plan. You say that you should not be 
responsible for the amount. The Plan denied your request. The Plan says the cost-sharing you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs, including chemotherapy drugs.  
 
  You have been asked to pay $411.26, which is 20% of the allowed amount for the Bimatoprost injection. The 
allowed amount is $2,056.30 (20% x $2,056.30 = $411.26). The Bimatoprost injection falls 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 waive the coinsurance for 
the Bimatoprost injection provided on January 28, 2022.