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

 
We decided that the Plan has to pay for the computed tomographic angiography services (71275 and Q9967) 
provided on July 14, 2021. 
 
You asked the Plan to pay for codes 71275 and Q9967. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 evidence based on Medicare criteria to support their 
reasoning for the denial of payment for these services. Therefore, we decided that the Plan has to pay for the 
computed tomographic angiography services (71275 and Q9967) provided on July 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient procedure provided on February 
16, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient procedure. You say that you feel you should only 
be charged a $35 copayment for a specialists office visit. The Plan denied your request. The Plan says the 
coinsurance applied 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 40% 
coinsurance for out of network surgery services in a PCP or specialists office.  
 
 
 
 
 You have been asked to pay $153.93 which is 40% of the allowed amount for the outpatient procedure. The 
allowed amount is $384.83 (40% x $384.83= $153.93). Outpatient procedures fall within the 
Physician/Practitioner services including doctors office visits 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 outpatient procedure provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were billed for seeing a PCP. 
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 each specialist visit.  
 
The record shows that you were seen by a gastroenterology specialist. Therefore, you have been asked to pay a 
$50 copayment for the office visit. The office visit falls within the Physician/Practitioner Services, Including 
Doctor's Office Visits 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 specialist 
office visit provided on December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs physician led wound 
care management, 24-hour nurse observation and cardiac monitoring. The Plan denied your request. The Plan 
says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital, having 
been admitted with sepsis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee 
requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide 
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can 
remain at the current acute care hospital until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for therapeutic phlebotomy services provided 
on November 9, 2021, and December 15, 2021. 
 
You asked the Plan to waive the copayments for the phlebotomy services. You say that you do not agree that 
the procedure should be under outpatient surgery. 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 $350 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay $135.73 for each visit for the phlebotomy services, which is less than the $350 
copayment. The total for both visits is $271.46. The phlebotomy services fall within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 therapeutic phlebotomy services provided on 
November 9, 2021, and December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 3, 2022, to January 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were only informed of a 
$90 emergency room copayment. 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 $295 per 
day for days 1-6 and $0 per day for days 7-90 for each inpatient admission.  
 
The file shows that you were in the hospital from January 3, 2022, to January 13, 2022. Therefore, you have 
been asked to pay $295 per day for the first 6 days of inpatient care. The total for your stay is $1,770 ($295 
copayment x 6 days = $1,770). The inpatient care 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 waive the copayment for inpatient hospital care provided from January 3, 2022, to 
January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 21, 2021. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says 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 Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on December 21, 2021.
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 December 10, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that your vitals were stable and you were told 
the hospital wouldn't be able to do anything else for you. The Plan denied your request. The Plan says since 
you were not transported by this ambulance, the service is not covered under your plan. 
 
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 December 10, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electroencephalogram (EEG) provided 
on January 4, 2022. We also decided that the Plan does not have to waive the copayment for laboratory services 
provided on February 14, 2022. 
 
You asked the Plan to waive the copayments for the EEG and lab services. You say that you were not aware of 
any copayment for the EEG. You says that you have also never had a copayment for blood work. 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 $105 
copayment for diagnostic procedures and tests provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for lab services provided at an 
outpatient hospital. 
 
You have been asked to pay a $105 copayment for the EEG. You have also been asked to pay a $35 copayment 
for the lab services. The total for both services is $140. The EEG and lab services 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 an electroencephalogram (EEG) provided on January 4, 2022. We also decided that the Plan 
does not have to waive the copayment for laboratory services provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) rendered by the out-
of-network (OON) provider on January 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids/services only when rendered by a Plan provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. The service in this case was rendered by an out-of-network 
provider with the Plan. The Plan pays for hearing aids/services only when rendered by a Plan provider. 
Therefore, we decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) rendered 
by the out-of-network (OON) provider on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 4, 2022, to January 11, 2022. We also decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on January 5, 2022. 
 
You asked the Plan to waive the copayments for the inpatient care and ambulance transportation. You say that 
you should not be responsible for the charges due to your COVID-19 diagnosis. 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 $325 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission. 
 
Your contract with the Plan also clearly says that you must pay a $250 copayment for each one-way ambulance 
trip. 
 
The file shows that you were in the hospital from January 4, 2022, to January 11, 2022. Therefore, you have 
been asked to pay $325 per day for the first 5 days of inpatient care. The total for the inpatient care is $1,625 
($325 copayment x 5 days = $1,625). The inpatient care falls within the Inpatient Hospital Care benefit 
category. You have also been asked to pay a $250 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. The total for all services is $1,875. 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 inpatient hospital care provided from January 4, 2022, to 
January 11, 2022. We also decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency intubation (31500) billed on August 5, 2021. 
 
You asked the Plan to pay for emergency intubation (31500). You say that the correct codes were assigned, and 
no coding changes are required. You say that the medical records should be reviewed, and the service 
reconsidered for payment. The Plan denied your request. The Plan says the documentation submitted did not 
include a procedure report detailing an emergency intubation. 
 
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 31500 is intubation, endotracheal, emergency 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 emergency intubation (31500). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the medical record does not include documentation of intubation. Therefore, CPT code 31500 cannot be 
verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency intubation (31500) have not been met. Therefore, we decided that 
the Plan does not have to pay for emergency intubation (31500) billed on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (85060) provided on February 4, 2022. 
 
You asked the Plan to pay for code 85060. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not rendered in the hospital inpatient setting. Therefore, we decided that the Plan does 
not have to pay for the laboratory service (85060) provided on February 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the member is skilled now and needs physical 
therapy. The Plan denied your request. The Plan says at the current level of function, the enrollee does not 
require daily skilled therapy services on an inpatient basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with secondary diagnosis code 
E87.1 and diagnosis related group (DRG) 038 provided from November 23, 2019, to November 30, 2019. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of secondary diagnosis code E87.1 with DRG 038. The Plan denied your request. The Plan says the 
medical records do not support the billing of secondary diagnosis code E87.1 with DRG 038. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E87.1. 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 inpatient hospital services. Our reviewer says that the medical records do not 
support the billing of secondary diagnosis code E87.1 with DRG 038. Our physician reviewer found the review 
indicates that the enrollee presented from a nursing home with complaints of a syncopal episode and fall, 
hitting her head. The enrollee's sodium level on presentation was 129. Per emergency room (ER) provider 
evaluation/impression the enrollee was admitted for syncope, traumatic injury of head, chest pain, and essential 
hypertension. The enrollee was diagnosed with hypo-osmolality, hypochloremia, and hyponatremia and the 
enrollee was treated with IV fluids and docusate sodium. While the enrollees presenting low sodium level is 
acknowledged, a suspected cause nor specific intervention was not noted in the record. The enrollee received 
IV fluids in the ER aimed at hydration. Per ER note, "Patient initially treated with NS 1 L IV at 125ml/hour for 
dehydration". Docusate sodium was noted to be ordered for constipation. One repeat sodium level note in 
record on November 25, 2019, within normal limits. As noted above, although the provider documented 
hyponatremia, reasonable support within the health record must be present for that diagnosis. The review has 
determined that the medical records did not support the billing of secondary diagnosis code E87.1 with DRG 
038.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services with secondary diagnosis code E87.1 and diagnosis related group (DRG) 038 
provided from November 23, 2019, to November 30, 2019.