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

 
We decided that the Plan does not have to waive the copayment for testing provided on March 4, 2022, and 
April 14,2022. 
 
You asked the Plan to waive the copayment for testing. You say that you shouldn't have to pay for both tests. 
The Plan denied your request. The Plan says the copayments applied are 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 $175 
copayment for advanced imaging and $125 copayment for other diagnostic tests and procedures.  
 
 
 You have been asked to pay a total of $300 ($125 + $175) copayment for the testing. Testing falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for testing provided on March 4, 2022, and April 14,2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can participate in the IRF therapy each 
day. The Plan denied your request. The Plan says the records do not show that the enrollee is able to take part 
in 3 hours of therapy 5 days per week, nor are they in need of a rehabilitation doctor to see you 3 times per 
week, nor do they need an intensive team for their care based on the standards set by Medicare. The services 
the enrollee needs can be provided safely in other settings, for example, a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. 
 
At the current functional level, the enrollee, does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not 
medically necessary based on lack of medical complexity and acute rehab nursing needs. Documentation does 
not support the medical necessity for admission to an IRF. 
 
While the enrollee may benefit from continued physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on September 20, 
2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you shouldn't be charged for this 
service. The Plan denied your request. The Plan says the copayment 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 $10 
copayment per visit to a primary care physician.  
 
You have been asked to pay $10 copayment for office visit. Office visits 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 copayment 
for office visit provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 
2, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the panel does 
not meet Medicare coverage criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. It appears that the testing may have been ordered by an unsolicited outreach 
telephone call to the enrollee. The testing services were requested solely for screening purposes. Screening 
services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease 
predisposition are not a Medicare benefit and are not covered. Therefore, we decided that the Plan does not 
have to pay for the hereditary cardiovascular screening provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93880 billed for date of service December 7, 
2021. 
 
You asked the Plan to pay for procedure code 93880. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 93880 is bundled into payment for code 76536.  
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 93880 
is a column II code to column I code 76536. 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 93880 billed for date of service December 7, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for an emergency room visit on March 8, 
2022. 
 
You asked the Plan to waive the $90 copayment for an emergency room visit March 8, 2022. You say that you 
should not be responsible for this copayment as this service was not available anywhere else. The Plan denied 
your request. The Plan says you must pay a $90 copayment for each emergency room visit. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 $90 copayment for an 
emergency room visit on March 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says coverage cannot be approved 
because the facility is more than 60 miles from the enrollee's residence. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
you had been treated for sepsis and required full assistance for transport and transfer and have dementia, 
however, documentation showed hemodynamic stability and no need for any specific treatment during 
transport requiring specially trained staff or equipment. As you did not require expert services or treatment 
during transportation, the ambulance transport will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nebulizer with compression on 
November 20, 2020. 
 
You asked the Plan to waive the coinsurance for a nebulizer with compression. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for a nebulizer with compression. The total allowed amount of the nebulizer with compression is 
$8.93, resulting in a coinsurance amount of $1.79. 
 
You have been asked to pay 20% coinsurance for a nebulizer with compression. A nebulizer with compression 
falls within the Durable medical equipment (DME) and related 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 coinsurance for a nebulizer with compression on November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 3, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. 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 March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amniotic membrane for surgical reconstruction services 
coded V2790 provided on September 28, 2021. 
 
You asked the Plan to pay for the amniotic membrane for surgical reconstruction services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not separately payable. 
 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 V2790 
is a column II code to column I code 65778 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the amniotic membrane for surgical reconstruction services coded V2790 
provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 panel was not billed with a single panel code as required. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the gene panel testing provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit on November 24, 2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you are looking to be 
reimbursed. The Plan denied your request. The Plan says the copayment and the amount the member has been 
reimbursed 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 a $50 
copayment for urgent care visit.  
 
You have been asked to pay a $50 copayment for urgent care visit. Urgent care visit falls within the Urgently 
needed 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 urgent care visit on 
November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2021, billed with 
codes 81292, 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 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 19, 2021, billed with codes 81292, 81294.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve five (5) additional HH SN visits (CPT code G0299 x5). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found the clinical documentation shows that you have clinical monitoring needs that would require 
the specialized skill of a nurse; therefore, five (5) skilled nursing visits are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve five (5) additional HH SN visits (CPT code G0299 x5).  
 
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 pay for the percutaneous transcatheter placement of intracoronary 
stent (92929) provided on November 1, 2021. 
 You asked the Plan to pay for the percutaneous transcatheter placement of intracoronary stent. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
no separate payment is made for this code. 
 
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 find that CPT code 92929 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92929 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the percutaneous transcatheter placement of intracoronary stent have not been met. Therefore, we decided 
that the Plan does not have to pay for the percutaneous transcatheter placement of intracoronary stent (92929) 
provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body, endosteal 
implant (D6010), surgical access to an implant body, second stage implant surgery (D6011) and therapeutic 
parenteral drug, single administration (D9610). 
 
You asked the Plan to pre-approve dental services. You say that you need the implants due to the lack of bone 
structure. You need to be able to have the bottom dentures stay in. You also say you have had several dentures 
made over the last 10 years and none will stay in even with adjustments and bonding agents. This is affecting 
your quality of life and you cannot afford the items not covered. The Plan denied your request. The Plan says 
the requested services are not covered with your Plan. 
 
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 
surgical placement of an implant body, endosteal implant (D6010), surgical access to an implant body, second 
stage implant surgery (D6011) and therapeutic parenteral drug, single administration (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic biometry office visit 
provided on May 18, 2022. 
 
You asked the Plan to waive the copayment for an ophthalmic biometry. You say that you could not have the 
surgery without the measurement. You say that this is a necessary part of the cataract removal process and you 
feel the $40 for the specialist visit is invalid. The Plan denied your request. The Plan says you have been 
charged the correct copayment 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 $40 
copayment for each in-network specialist's office visit. Covered service includes one pair of eyeglasses or 
contact lenses after each cataract surgery that includes insertion of an intraocular lens.  
 
 
 You have been asked to pay a $40 copayment for an ophthalmic biometry. an ophthalmic biometry falls within 
the Vision Services (Medicare-covered) 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 ophthalmic biometry office visit provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered by the Plan 
with no copayment. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says the lab billed multiple individual codes with the same date of 
service. 
 
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. It is not appropriate to separately report CPT 81404 from the panel. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 22, 2021.