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

 
We decided that the Plan does not have to pay for the PrismRA Next Generation Sequencing (NGS) test 
provided on March 23, 2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that this test is only performed by your lab and 
was ordered by the patient's doctor to inform the patient's treatment. The Plan denied your request. The Plan 
says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for any NGS testing to be covered, the 
test must have FDA approval or clearance. The PrismRA test does not currently have FDA approval or 
clearance. Based on this information, we decided that Medicare rules for coverage of the PrismRA testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA Next Generation 
Sequencing (NGS) test provided on March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the ankle provided on May 19, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you would not have a copayment if 
you had gone to a free-standing clinic or office setting. 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 $50 
copayment for X-rays and ultrasounds in an outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for the X-rays. The X-rays fall 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 X-rays of the ankle provided on May 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
April 5, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that while you did have these services, 
you think the hospital is trying to scam the Plan. The Plan denied your request. The Plan says you were charged 
this copayment 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 $40 
copayment for emergency care.  
 
You have been asked to pay a $40 copayment for the ER visit. 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 emergency room (ER) visit you had on April 5, 2022.  
 Your complaint about this bill being a false claim or a scam is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99501 and 99214 billed for date of service 
April 23, 2022. 
 
You asked the Plan to pay for procedure codes 99501 and 99214. You did not provide a specific argument for 
coverage with your appeal request. The Plan denied your request. The Plan says procedure code 99501 is 
considered bundled and not separately payable. The Plan also says that procedure code 99214 is not covered 
because unauthorized, non-plan care is not covered. 
 
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 99501 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99501 is not separately payable.  
 
In relation to code 99214, 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve code 99214. We 
found no exception that would require the Plan to pay for this service. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 99501 and 99214 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99501 and 99214 billed for date of service April 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy treatment provided on 
April 6, 2022. 
 
You asked the Plan to waive the copayment for the radiation treatment. You say that each treatment session 
should only cost a total of $30. 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 $30 
copayment for each radiation therapy service.  
 You have been asked to pay a $30 copayment for the radiation treatment. The radiation treatment 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 radiation therapy treatment provided on April 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an extremity 
study (ultrasound) provided on April 4, 2022. 
 
You asked the Plan to waive the copayments for the specialist visit and ultrasound. You say that the services 
should be covered in full. 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 $50 
copayment for specialist services. 
 
 Your contract with the Plan also clearly says that you must pay a $170 copayment for radiological diagnostic 
services, such as ultrasounds. 
 
You have been asked to pay $20.39 for the specialist services, which is less than the $50 copayment per the 
EOC. The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 
benefit category. You have also been asked to pay $168.45 for the ultrasound, which is less than the $170 
copayment per the EOC. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies benefit category. The total for the services is $188.84. 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 a specialist office visit and an extremity study (ultrasound) provided on April 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography provided on April 20, 
2022. 
 
You asked the Plan to waive the copayment for an echocardiography. You say that you do not understand why 
you received this bill, you feel it should be overturned. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for an echocardiography. An echocardiography 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 an echocardiography provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services you had on January 31, 
2022. 
 
You asked the Plan to pay for the office visit and related services. You say that this doctor has been your 
provider for 25 years.  You said that the plan has paid for these services before. You said that you do not 
understand this denial. The Plan denied your request. The Plan says the provider you saw has opted out of the 
Medicare program, so these services cannot be paid. 
 
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 the office 
visit and related services you had on January 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on February 28, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this should be paid as this is a Medicare 
replacement plan. The Plan denied your request. The Plan says that the claim has a missing or invalid code. A 
corrected claim is needed for payment to be made. 
 
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 has not provided a valid denial rationale in this case. The rationale is 
simply that the claim is missing a valid procedure code; however, no specifics are noted as to why the code is 
invalid. This is an active code that is payable by Medicare. Without a valid reason to support that this code is 
not valid, the denial is not substantiated. Therefore, we decided that the Plan has to pay for the anesthesia 
services provided on February 28, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on March 16, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you saved the Plan money by 
not being transported. The Plan denied your request. The Plan says non-transport ambulance services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on March 16, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for non-transport ambulance 
services provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the intraoral 
periapical x-ray (D0220) provided by a network provider on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you assumed the services were covered. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation (D0140) and the intraoral periapical x-ray (D0220) were 
exhausted on date of service February 23, 2022. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140) and the intraoral periapical x-ray (D0220) provided by a network provider 
on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #13 and 29 (D2751) and core build up 
on tooth #13 and 29 (D2950). 
 
You asked the Plan to pre-approve crowns and core build up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says a crown (D2751) and core build up (D2950) are not 
covered by your dental benefits. 
 
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. 
 
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 pre-approve a 
crown on tooth #13 and 29 (D2751) and core build up on tooth #13 and 29 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) and the medicaments for 
home use (D9630) provided by a network provider on March 31, 2022. 
 
You asked the Plan to pay for the gingival irrigation (D4921) and the medicaments for home use (D9630). You 
say that you assumed the services were covered. The Plan denied your request. The Plan says the services are 
not covered benefits. 
 
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. 
 
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 
gingival irrigation (D4921) and the medicaments for home use (D9630) provided by a network provider on 
March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidural injection (64484) provided on February 23, 
2022. 
 
You asked the Plan to pay for the epidural injection (64484). You say that the transforaminal epidural with 
fluoroscopic guidance was medically necessary due to the enrollee's level of pain. You say that the medical 
records should be reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan 
says the medical records do not support procedure code 64484-RT-59. 
 
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 64484 is injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(List separately in addition to code for primary procedure).  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the transforaminal epidural injection (64484). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the medical documentation does not support an injection at an additional level. 
 
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 epidural injection (64484) have not been met. Therefore, we decided that the 
Plan does not have to pay for the epidural injection (64484) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown on tooth #19. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says tooth #19 shows more than 50% of the bone around the tooth is gone. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 the crown. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found that there is 
about 50% loss of bone around tooth #19, and no obvious caries or existing restorations. There is no loss of 
structure and no indication as to why a crown would be considered necessary as a crown is a restoration placed 
to strengthen the remaining tooth where there has been significant loss of the coronal structure from decay or 
fracture. One issue would be the loss of about half of the supporting bone around the tooth, making for a poorer 
long term prognosis of #19. The more significant issue is there is no loss of structure that needs to be replaced 
with a crown.  Without a clear need for the procedure, the plan criteria for a crown has not been met as the 
procedure would not be necessary or reasonable.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown on tooth #19.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 43275, 43262 and 43277 billed on 
December 29, 2021. 
 
You asked the Plan to pay for procedure codes 43275, 43262 and 43277. You say that the medical 
documentation should be reviewed, and the claim reprocessed accordingly for payment. The Plan denied your 
request. The Plan says procedure codes 43275, 43262 and 43277 are inclusive to procedure code 43274. 
  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 codes 43275, 43262 and 43277 are column II codes to column I code 
43274; however, 43262 and 43277 were 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 procedure codes 43275, 43262 and 43277. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report does not support that codes 43262 and 43277 were separate procedures from 
code 43274. In addition, procedure code 43275 has not been billed with an appropriate modifier to bypass the 
edit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 43275, 43262 and 43277 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 43275, 43262 and 43277 billed on December 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on January 20, 
2022, billed with codes 81286, 81413, 81414, 81442, 81161 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the provided records. The Plan denied your request. The Plan says these are bundled 
services which were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The rules also say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. In addition, the provided test requisition form is illegible. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the cardiovascular genetic testing provided on January 20, 2022, billed with 
codes 81286, 81413, 81414, 81442, 81161 and 81479.