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

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on February 16, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. 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 computed tomography (CT) of the head or brain (70450) 
provided on February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have dialysis 
treatments three times per week the center is not able to help you get from home to the facility. You need to 
have continued transportation. The Plan denied your request. The Plan says you have exhausted the maximum 
benefit of 36 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an inpatient hospital stay provided from 
December 30, 2021, to January 4, 2022. 
 
You asked the Plan to lower the copayment for the inpatient hospital stay. You say that you believe the 
copayment amount should be lower. The Plan denied your request. The Plan says the copayment amount 
charged is less than the proper copayment amount for the dates of service. Therefore, the claim was processed 
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 in year 2021 clearly says that you must 
pay a $150 copayment per day (per Medicare-covered stay) which includes day of admission and day of 
discharge for Days 1-7 and your contract with the Plan in year 2022 Cleary says that you must pay a $125 
copayment per day (per Medicare-covered stay) which includes day of admission and day of discharge for 
Days 1-6. The date of admission to inpatient hospital stay was December 30, 2021, and the date of discharge 
was January 4, 2022. There was a total of 2 days stayed in the inpatient hospital in the year of 2021 with a 
copayment amount of $300 (2 days x $150 copayment). There was a total of 4 days stayed in the inpatient 
hospital in the year of 2022 with a copayment amount of $500 (4 days x $125 copayment). The total 
copayment amount for the inpatient hospital stay is $800 ($300 copayment + $500 copayment). The Plan 
charged $750 copayment amount which is less than the total copayment amount of $800. 
 
You have been asked to pay a $750 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital 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 lower the copayment for an 
inpatient hospital stay provided from December 30, 2021, to January 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from January 1, 2022, through January 4, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 29, 2021, 
through December 18, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still have needed skilled care, the Plan is not required to pay for more than 100 days 
of SNF coverage during this benefit period.  The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a 
hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have 
to pay for the inpatient skilled nursing facility (SNF) care provided from January 1, 2022, through January 4, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided December 17, 2021 while 
outside of the U.S. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were in Turks and Caicos and was required 
to have a negative COVID test in order to return to home. The reimbursement was not approved and you do not 
understand why. The COVID test was a requirement by the President of the United States and should be 
covered. The Plan denied your request. The Plan says COVID-19 test while traveling outside of the US is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for 
the COVID-19 test provided December 17, 2021 while outside of the U.S.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 9, 2022, to April 
19, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this inpatient care was medically necessary for this 
enrollee. The Plan denied your request. The Plan says the enrollee received inpatient hospital care from March 
24, 2022, until April 7, 2022. The enrollee was discharged to a skilled nursing facility and was re-admitted to 
the same hospital for the same diagnosis within 24 hours. The enrollee was kept on the same dialysis schedule. 
Therefore, these admissions are related, and separate payment will not be made. The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that this 
inpatient hospital readmission was the result of a premature discharge from the same hospital. Our physician 
reviewer found that the enrollee with a history of diabetic neuropathy, hypertension, blood pressure and end 
stage renal disease (ESRD) started on hemodialysis in April 2022. He presented to the emergency department 
on April 9, 2022, following a previous hospital discharge on April 7, 2022, with worsening shortness of breath; 
spontaneous awakening trials (SATs) at the nursing home, 78% on room air, not on home oxygen, and was 
again admitted to the same hospital for pulmonary edema requiring dialysis. The enrollee was kept on the same 
dialysis schedule and was treated for congestive heart failure (CHF). The review has determined that the 
readmission was medically necessary; however, the readmission was the result of a premature discharge from 
the same hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital care provided from April 9, 2022, to April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on February 2, 2022. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel provided 
including testing for the FANCC gene. This means the entire panel is not covered. Based on this information, 
we decided that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided on 
February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy of right breast and placement of a 
locating device using x-ray with needle (19081) completed on March 4, 2022. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you should not be responsible for 
payment because the provider did not explain the procedure you received. The Plan denied your request. The 
Plan says the copayment was assessed correctly. You received a covered diagnostic mammogram and 
subsequent breast biopsy. The biopsy is a surgical procedure and was performed in an outpatient hospital 
setting. The Plan also says that you contacted a representative prior to the date of service and were advised that 
outpatient procedures and/or surgery at an outpatient hospital have a $100 copayment.  
 
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 outpatient procedures and/or surgery at an Outpatient Hospital.  
 
 
 You have been asked to pay a $100 copayment for a breast biopsy. Breast biopsies fall within the Outpatient 
Surgery 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 biopsy of right breast and 
placement of a locating device using x-ray with needle (19081) completed on March 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 27, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you opted to go to an urgent care due to the 
time of year. You say that the coronavirus was rampant in your area at the time. You say that the care you 
needed could have been done at an urgent care. You also say that you feel this service should be covered. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
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 January 27, 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 the ambulance response and treatment, no 
transport, (A0998) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on 
March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the enrollee was unaware that 
they must get services in-network. The Plan denied your request. The Plan says the services were provided out-
of-network and were not approved in advance. 
  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 hospital outpatient clinic visit (G0463) 
provided on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (67900, 67904) provided on December 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has 
been exceeded.  
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 codes 67900 and 67904 is 1. The MAI value for this code is 2. You billed 2 
units of each of these codes, exceeding the MUE. 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 the 
services (67900, 67904) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told by your agent that this provider 
would be covered. The Plan denied your request. The Plan says they confirmed there is no evidence that the 
enrollee received any incorrect coverage information from the Plan prior to receiving the services. Therefore, 
payment for the rendering OON provider is denied. 
 
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 an office visit provided on February 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on 
December 10, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99221 is not supported in the medical record. Specifically, this code was billed with 
modifier -57. The documentation shows that the major procedure (Code 10061) was performed on December 
11, 2021. This means that this service is not included in a global period; therefore, the billing of modifier -57 is 
not appropriate. Based on this information, we decided that Medicare rules for coverage of the initial hospital 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial 
hospital care services coded 99221 provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on January 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from February 11, 
2022, to February 13, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not informed that you would 
be billed for these medications. You say that you were in the hospital previously and administered the same 
medications. You say that you were not billed for these previously. You also say that you feel you should not 
be responsible for this bill. The Plan denied your request. The Plan says the claim processed correctly. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from February 11, 2022, to February 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of breast implant with capsulectomy (19731) and 
surgical repair and/or reconstruction procedures on the breast (19328) provided July 23, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the documentation does not support 
that the service meets coverage requirements. 
 
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 pay for the surgical procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the available documentation does not support that removal of the capsule and the 
removal of the implant were medically reasonable and necessary for the enrollee in this case. There was no 
documented evidence of implant rupture, breast malignancy, capsular contracture, implant hypersensitivity, or 
infection. A medically necessary indication for the procedure is not identified. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for removal of breast implant with capsulectomy (19731) and surgical repair and/or 
reconstruction procedures on the breast (19328) provided July 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the 13 PT visits provided from January 11, 
2022, to February 22, 2022. 
 
You asked the Plan to waive the copayment for the PT visits. You say that you were never informed of a 
copayment for each visit. The Plan denied your request. The Plan says the copayment was applied 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 $15 
copayment at an outpatient hospital setting for physical therapy visits.  
 
You have been asked to pay $195 ($15 copay x 13 visits) for the PT visits. The PT visits fall within the 
Outpatient rehabilitation services 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 
the 13 physical therapy (PT) visits provided from January 11, 2022, to February 22, 2022.