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

 
We decided that the Plan does not have to pay for 2 units of procedure code 95117 billed for date of service 
March 28, 2022. 
 You asked the Plan to pay for 2 units of procedure code 95117. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95117 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 2 units of 
procedure code 95117 have not been met. Therefore, we decided that the Plan does not have to pay for 2 units 
of procedure code 95117 billed for date of service March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the heart imaging (myocardial perfusion 
imaging) and drug injection rendered on May 25, 2022. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for Medicare-covered nuclear medicine at a freestanding provider and a 20% coinsurance for 
Medicare Part B-covered drugs. 
 
Review of the file shows that you received imaging of your heart on May 25, 2022. You have been asked to 
pay a $100 copayment for these services. This item/service falls within the Medicare-covered nuclear medicine at a freestanding provider 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.  
 
The file shows that you received a Part B drug injection on May 25, 2022. You have been asked to pay a 20% 
coinsurance for these services. This item/service falls within the Medicare-covered Part B 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 cost sharing for the heart imaging (myocardial 
perfusion imaging) and drug injection rendered on May 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (0037U) provided on May 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as 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. 
 
We looked at the file and the rules. The records show that the enrollee has advanced cancer. The Plan has not 
shown that the specimen does not meet one of the exceptions for the billed date of service. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Based on this information, we decided that Medicare rules for coverage of the testing services 
have been met. Therefore, we decided that the Plan has to pay for the laboratory services (0037U) provided on 
May 22, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and noncovered 
item or service (A9270) self-administered drug (J8499) provided June 8, 2022 to June 9, 2022. 
 
You asked the Plan to pay for the self. You say that you received a letter stating that you owe a balance for a 
hospital stay from June 8, 2022 to June 9, 2022. Please explain why the remaining charges are not covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $120 
copayment for in-network emergency room. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 
 
You have been asked to pay $389 ($120 copayment for in-network emergency room services and $269 for self-
administered drugs) for the emergency services. The self-administered drugs requested here are not among the 
types which are covered by Medicare Part B. These items/services fall within the Emergency care and 
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 pay for the emergency 
department visit (99285) and noncovered item or service (A9270) self-administered drug (J8499) provided 
June 8, 2022 to June 9, 2022.  
 
Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Cxbladder 
Triage testing (81479) provided June 23, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence support the use of 
Cxbladder Triage test as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says medical records not received to substantiate services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory service have been met. 
The Plan made multiple attempts to obtain the needed medical records from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure, 
Cxbladder Triage testing (81479) provided June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L0560 billed for date of service January 29, 
2021. 
 You asked the Plan to pay for procedure code L0560. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code L0560 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code L0560 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code L0560 billed for date of service January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for retinal imaging provided on August 5, 2022. 
 
You asked the Plan to pay for retinal imaging. You say that the service should be covered. The Plan denied 
your request. The Plan says that there is a member responsibility of $39 for this 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 does not say in clear and accurate terms 
how much you should expect to pay for retinal imaging.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $39 for 
retinal imaging. The Plan contract does not clearly say how much enrollees must pay for retinal imaging. This 
means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Additionally, this 
service is diagnostic imaging, and the EOC indicates there is no cost sharing for this. Therefore, we decided 
that the Plan has to pay for retinal imaging provided on August 5, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service November 1, 
2021. 
 You asked the Plan to pay for procedure code 97530. You say that this service is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says payment for code 97530 is bundled 
into payment for code 92526. 
 
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 97530 
is a column II code to column I code 92526. 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 97530 billed for date of service November 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service March 21, 2022, billed with code 99153. 
 You asked the Plan to pay for procedure code 99153. You say that this should be covered. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service March 21, 2022, billed 
with code 99153.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the MRI (72141) provided on December 17, 2021. 
 
You asked the Plan to pay for the MRI (72141). You say that procedure code 72141 was performed separately 
and was billed with the appropriate modifier. You say that the medical records should be reviewed, and the 
claim processed for payment. The Plan denied your request. The Plan says that there are no modifiers that are 
allowed with this code pair. 
 
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, the documentation submitted does not support that procedure code 
72142 was billed for the same date as service as 72141. This means that procedure code 72141 is payable. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the MRI 
(72141) provided on December 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits and cataract removal 
surgery provided from February 8, 2022, to May 19, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits and cataract removal surgery. You say 
that you believe that the plan should review and reconsider the copayments. The Plan denied your request. The 
Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $30 copayment per visit for Physician/Practitioner services/specialist services.  
 
The enrollee has been asked to pay a $30 copayment per visit for specialist office visit and cataract removal 
surgery. The total you are being asked to pay is $90 ($30 x 3 visits = $90). This item/service falls within the 
Physician/Practitioner services/specialist services benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist office visits and cataract removal surgery provided from February 8, 2022, to May 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), mandibular partial denture (D5214), 
and a maxillary partial denture (D5213), provided by a participating provider. 
 
You asked the Plan to pre-approve a crown, mandibular partial denture, and a maxillary partial denture. You 
say that you believe these services should be covered. The Plan denied your request. The Plan says the 
rendered dental 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 pre-approve a 
crown (D2740), mandibular partial denture (D5214), and a maxillary partial denture (D5213), provided by a 
participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology, target genomic sequencing 
(81479) provided April 3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this determination and 
believes that the biomarker testing services for the enrollee should be a covered Plan benefit. The Plan denied 
your request. The Plan says this test is considered experimental and investigational and not medically necessary 
because its role remains uncertain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. The testing at issue does not have FDA approval or FDA clearance 
as a companion in vitro diagnostic or an FDA approved, or FDA cleared indication for use in the enrollee's 
cancer. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology, 
target genomic sequencing (81479) provided April 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total right hip arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has only participated in two physical therapy visits. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have advanced joint disease clearly demonstrated in the records. The 7/1/22 x-
rays of the right hip are noted to show joint space narrowing, subchondral sclerosis, subchondral cysts all 
suggestive of degenerative joint disease. As the x-rays state that the findings are suggestive of degenerative 
joint disease, advanced disease is not demonstrated. Additionally, there has not been an adequate failure of 
conservative therapy documented. Conservative treatment included activity modifications, low-impact 
exercises, physical therapy evaluation, NSAIDs, and tramadol. On the physical therapy evaluation, she was 
noted to have good rehabilitation potential. No further therapy visits were provided to demonstrate failure. 
Therefore, there has not been an adequate failure of conservative therapy documented. 
 
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 pre-approve a total right hip arthroplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494-50 billed for date of service October 
5, 2021. 
 
You asked the Plan to pay for procedure code 64494-50. You say that this claim should be processed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494-50 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64494-50 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64494-50 billed for date of service October 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the Plan does not cover out-of-network services rendered. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve neurology visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says in most cases, the enrollee will need approval from their primary care 
provider (PCP) before using other providers. This approval is called a referral. 
 
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 
neurology visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 26, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81317, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says you should have billed a single panel code 
instead of individual lab codes. 
 
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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. 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 genetic testing provided on 
May 26, 2022, billed with codes 81201, 81292, 81295, 81298, 81317, and 81334.