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

 
We decided that the Plan does not have to waive the coinsurance for the Medicare part B drugs provided on 
April 12, 2021, November 12, 2021, and December 9, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare part B drugs. You say that the coinsurance 
amount for the service is too high. The Plan denied your request. The Plan says the proper coinsurance was 
applied for each date of service. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug. On April 12, 2021, the total amount charged was 
$3,617.14 with a coinsurance amount of $723.43 ($3,617.14 total amount x 20% coinsurance). On November 
12, 2021, the total amount charged was $3,377.10 with a coinsurance amount of $675.42 ($3,377.10 total 
amount x 20% coinsurance). On December 9, 2021, the total amount charged was $3,467.42 with a coinsurance 
amount of $693.48 ($3,467.42 total amount x 20% coinsurance). The total amount of the coinsurance for all 
dates of service was $2,092.33 ($723.43 coinsurance + $675.42 coinsurance + $693.48 coinsurance). 
 
You have been asked to pay a 20% coinsurance for the Medicare part B drugs. The Medicare part B drugs 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 Medicare part B drugs provided on April 12, 2021, November 12, 2021, and December 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99350 billed for date of service March 13, 2019. 
 
You asked the Plan to pay for procedure code 99350. You say that you billed this service correctly.  You said 
that you have submitted other claims for this same service that have been paid, so you don't understand why 
this one was not paid. The Plan denied your request. The Plan says that it did not complete a review of your 
appeal request in a timely manner. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it appears as though the Plan initially denied payment for this code 
due to 'code not appropriate for service billed'.  However, the Plan has provided no explanation as to how they 
came to that conclusion.  In addition, the Plan has failed to provide any evidence that the billing was incorrect. 
Therefore, we decided that the Plan has to pay for procedure code 99350 billed for date of service March 13, 
2019.  
 
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: 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 appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 while the enrollee may benefit from physical and/or occupational therapy, the 
enrollee will not tolerate and does not need intensive therapies consisting of at least 3 hours of therapy per day for at least 5 days per week with a multidisciplinary approach to rehabilitation. At the current level of function, 
the enrollee's rehabilitation needs can be safely met at a lower intensity setting such as a skilled nursing facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eyelash revision procedure performed 
on October 29, 2021. 
 
You asked the Plan to waive the copayment for the eyelash revision. You say that you feel you should not have 
to pay for the procedure. 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 each visit to diagnose or treat diseases and conditions of the eye.  
 
You have been asked to pay $22.04, which is less than the $40 copayment for the eyelash revision. The eyelash revision falls within the Vision Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an eyelash revision procedure performed on October 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were not informed of any 
additional costs for the 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 $200 
copayment for diagnostic radiology services in a provider's office or freestanding radiology center.   
You have been asked to pay $171.66, which is less than the $200 copayment for the CT scan. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a computed tomography (CT) scan of the thorax provided on 
December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy on October 7, 2021 to 
October 29, 2021. 
 
You asked the Plan to waive the copayments for radiation therapy. You say that you should not be responsible 
for the copayment. The Plan denied your request. The Plan says the copayment 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 $60 
copayment per provider, per date of service for radiation therapy. There were 15 radiation therapy visits, 
resulting in a total cost-sharing amount of $900.  
 
You have been asked to pay a $60 copayment per provider, per date of service for radiation therapy. Radiation 
therapy falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for radiation therapy on October 7, 
2021 to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Traditional Medicinals Organic Smooth Move Tea 
purchased on January 1, 2022. 
 
You asked the Plan to reimburse you for Traditional Medicinals Organic Smooth Move Tea. The Plan denied 
your request. The Plan says tea is not a covered expense; therefore, the Traditional Medicinals Organic Smooth 
Move stimulant laxative senna peppermint tea is not reimbursable. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter 
items must be included on the Plans allowed items list. 
 
 
 
 
 We looked at the file and the Plans rules. The file shows that tea is not a covered item under the Pick Your 
Perks benefit. Therefore, we decided that the Plan does not have to reimburse you for Traditional Medicinals 
Organic Smooth Move Tea purchased on January 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility services provided on November 26, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assisted living facility services. You say that the facilities staff did not get the 
proper authorization and the physician provided the services because it was medically necessary. The Plan 
denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
referral from the enrollee's primary care physician or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for assisted living facility services provided on 
November 26, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on January 21, 
2021. 
 
You asked the Plan to pay for moderate sedation services. You say that these services were billed correctly. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 99152 and 45380. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. Modifier -59 was billed with these services; however, the use of this modifier is not supported in the record. Modifier -59 and other NCCI-associated modifiers should not be 
used to bypass an NCCI PTP edit unless the proper criteria for use of the modifier are met. 
 
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 45380 
is a column II code to column I code 99152; however, 45380 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 moderate sedation services. Our reviewer says that the use of 
the -59 modifier is not supported in the medical record. Our reviewer found that the enrollee received services 
on January 21, 2021. The provider reported CPT code 99152 - moderate sedation services. The procedure 
report describes a colonoscopy with biopsy and moderate sedation. Modifier 59 is inappropriate to report with 
this procedure, and it is included with the colonoscopy procedure. Documentation does not support a separate 
distinct procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for moderate sedation services (99152) provided on January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumpectomy and placement of the BioZorb implant 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that Biozorb is considered investigational and not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The record indicates 
that the enrollee has stage 0 breast cancer and is undergoing lumpectomy. The record does not indicate that the 
enrollee is undergoing mastectomy. The records do not indicate that the requested service is to improve the 
function of a body structure altered by disease. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumpectomy and placement of the BioZorb implant for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on August 17, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arterial puncture rendered on July 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 36600 (arterial puncture) and 36513 (therapeutic apheresis 
for platelets). Code 36600 is a column II code with a modifier indicator of 1 when billed with column I code 
36513. Code 36600 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the arterial puncture rendered on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Magnetic resonance imaging (MRI) on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for a Magnetic resonance imaging (MRI). You say that you are 
unable to make the copay of $100 work on your fixed income. The Plan denied your request. The Plan says the 
copayment 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 $100 
copayment for Magnetic resonance imaging (MRI).  
 
You have been asked to pay a $100 copayment for Magnetic resonance imaging (MRI). Magnetic resonance 
imaging (MRI) falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a Magnetic resonance 
imaging (MRI) on November 2, 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 6, 
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 Current Procedural Terminology (CPT) code 83789 59 (1 unit) remains not supported 
 
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 83789 is "Mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen." 
 
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 in the medical records. Our reviewer found the documentation does not specify 
what "the not elsewhere specified" procedure code is being billed for. The laboratory report documents 
specimen validity testing which would be inclusive to urine drug screen per Medicare guidelines. 
 
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 laboratory services provided to the enrollee on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 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 lab services provided on September 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient laboratory services (83036, 
80061, 36415, 80053) provided on August 3, 2021. 
 
You asked the Plan to waive the copayment for the outpatient laboratory services. You say that the services 
should be covered with only a $10 copayment. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided, you received multiple tests in an office setting or imaging 
center. 
 
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 up to a 
$50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay up to a $33.66 copayment for outpatient laboratory services. Laboratory services 
falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient laboratory services (83036, 80061, 36415, 80053) 
provided on August 3, 2021.