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

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the chest without contrast. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no recent x-rays of the chest or other chest imaging first performed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the CT of the neck 
includes contrast injection and the requested CT of the chest could be obtained after the same injection. The 
cervical lymphadenopathy may be associated with mediastinal lymphadenopathy and the position that a chest 
x-ray is needed first is not valid. Even if a chest x-ray were to be negative the presence or absence of 
mediastinal lymphadenopathy would not be accurately assessed. The requested CT of the chest is in the best 
interests of the patient. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the chest without contrast.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
26, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service November 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
August 1, 2021, to August 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on August 1, 
2021, to August 30, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray exam of the chest (71046), the 
laboratory service (87804), and the inpatient hospital admission provided from October 19, 2021, through 
November 19, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $325 copayment per admission for each medically 
necessary inpatient stay. You must pay a $10 copayment for diagnostic lab services and diagnostic procedures 
and tests (per day, per facility). Additionally, you must pay a $10 copayment for each basic imaging service.  
 
You have been asked to pay $345 ($325 + $10 + $10) for the basic imaging service provided on October 19, 
2021, the diagnostic laboratory service provided on November 10, 2021, and the inpatient hospital admission 
provided on November 19, 2021. 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 the x-ray exam of the 
chest (71046), the laboratory service (87804), and the inpatient hospital admission provided from October 19, 
2021, through November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection provided on December 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied 
your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the injection provided on December 10, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 22, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the appointment was an annual 
physical and there should be no copayment. The Plan denied your request. The Plan says office notes from the 
provider show that the office visit was also a follow up for medication. Therefore, the proper copayment was 
applied. 
 
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 primary care doctor visit for Medicare-covered benefits.  
 
  You have been asked to pay a $30 copayment for an office visit. The office visit falls 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 copayment for an office visit provided on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) 
for a power wheelchair. 
 You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says an expandable controller (E2377) and harness (E2313) cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found an expandable controller is an electronic system that is capable of accommodating one or more 
additional features and can operate 3 or more powered seating options. The enrollee has a neurologic disorder 
with functional deficits. The requested accessories are not medically necessary as she does have use of her 
hands and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an expandable controller (E2377) and harness (E2313) for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
29, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service December 29, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
25, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says it has overturned the denial for code 93976 and this 
was paid.  The Plan says that payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 25, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy, flexible; with biopsy, single or multiple 
(45380) and the colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by the snare 
technique (45385) rendered by the out-of-network (OON) provider on October 22, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the colonoscopy, flexible; with biopsy, single or multiple (45380) and the 
colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by the snare technique (45385) 
rendered by the out-of-network (OON) provider on October 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay the copayment for a diagnostic ultrasound provided on August 9, 
2021. 
 
You asked the Plan to pay the copayment for the diagnostic ultrasound. You say that you would like the Plan to 
pay for the procedure. The Plan denied your request. The Plan says the allowed amount for the service 
provided is less than the Plan's benefit copayment amount. Therefore, the proper copayment was applied. 
 
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 $150 
copayment for Medicare-Covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility. The total amount allowed was $93.78 which is less than the 
copayment amount of $150. Therefore, only $93.78 was charged as the copayment amount. 
 
  You have been asked to pay a $93.78 copayment for the diagnostic ultrasound. The diagnostic ultrasound falls 
within the Outpatient Diagnostic Test 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 pay the copayment for a diagnostic ultrasound provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540 
83550, 83970, 84100) provided on October 13, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement to include 
these services in the dialysis. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. 
 Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540 
83550, 83970, 84100) provided on October 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
24, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not call and request 
the ambulance. You also say you should not have to pay the copayment for it. 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 $285 
copayment for in-network ambulance services.  
 
 
 The ambulance record shows you were transported by ambulance on November 24, 2021. You have been asked 
to pay a $285 copayment for ambulance services. Ambulance services falls within the Ambulance 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 ambulance services provided on 
November 24, 2021.  
 
Your complaint about not calling and requesting the ambulance 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient office visit (99205) 
electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided October 
29, 2021. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that you saw a cardiologist and had 
inquired and had been told that the visit was fully preauthorized by the Plan on that day. You cannot afford to 
pay this bill. The Plan denied your request. The Plan says the claim was processed with the correct cost share 
applied per the Evidence of Coverage. 
 
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 35% 
coinsurance for out of network specialist's office visits.  
 You have been asked to pay $67.54 ($64.63 + $2.91) 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 coinsurance for the outpatient office visit (99205) electrocardiogram, routine ECG with at least 
12-leads; interpretation and report only (93010) provided October 29, 2021.
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 
September 22, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you felt like nothing was 
accomplished during the office visit so there should be no copayment. The Plan denied your request. The Plan 
says the proper copayment was applied for the service rendered and the quality-of-care concerns were 
addressed. 
 
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 $45 
copayment for each in-person specialist visit.  
 
  You have been asked to pay a $45 copayment for the specialist office visit. the specialist office visit falls 
within the each in-person specialist visit 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 September 22, 2021.  
 
Your complaint about your experience with this provider 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 anesthesia for procedures on eye; lens surgery (00142) 
provided on January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia for procedures on eye; lens surgery. You say that this provider is the 
only anesthesia provider this facility uses. You also say that the patient had no choice and should not be 
penalized for being forced to use an out-of-network anesthesia provider. The Plan denied your request. The 
Plan says the services were not authorized by network/primary care providers, and the referral was not 
authorized by the attending physician. The Plan also says that this provider is not a network provider with the 
Plan, and they have also determined that these services are not urgent or emergent, nor were they 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 anesthesia for procedures on eye; lens surgery 
(00142) provided on January 6, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on November 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that the location code must reflect the location in 
which the services were rendered. An exception is when the enrollee is a registered inpatient. In those cases, 
the correct POS code is for inpatient no matter where the services took place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient POS code. 
The records support that the enrollee was registered inpatient at this time. Therefore, we decided that the Plan 
does not have to pay for radiology services provided on November 10, 2021.