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

 
We decided that the Plan does not have to reimburse you for the 4 at-home coronavirus test kits purchased on 
December 30, 2021. 
 
You asked the Plan to reimburse you for the at-home coronavirus test kits. You say that it stated on the 
reimbursement form that up to February 21, 2022, will be reimbursed. You say that you were advised to fill out 
the form for reimbursement but were sent a regular Medicare Advantage reimbursement form, and not a 
coronavirus reimbursement form. The Plan denied your request. The Plan says the at-home coronavirus test kits 
were not a covered benefit at the time of purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage applies to eligible tests that are 
purchased on or after February 1, 2022, through the end of the federal public health emergency (PHE) or 
December 31, 2022, whichever is earlier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home coronavirus test kits have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for the 4 at-home coronavirus test kits purchased on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88329 billed for date of service November 3, 
2021. 
 
You asked the Plan to pay for procedure code 88329. You say that this is a separate procedure. The Plan denied 
your request. The Plan says payment for code 88329 is bundled into payment for code 88331.  
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 88329 
is a column II code to column I code 88331. 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 88329 billed for date of service November 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia provided 
on December 9, 2021. 
 
You asked the Plan to pay for laparoscopy, surgical; repair initial inguinal hernia. The Plan denied your 
request. The Plan says per Medicare guidelines, this provider specialty does not have the capacity to bill 
directly for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia provided on  
December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visits with an out-of-network 
pulmonologist you had on March 8, 2021, and March 5, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network pulmonology visits. You say that you 
believe this is an error because you have been going to this provider for years. The Plan denied your request. 
The Plan says you were charged this deductible correctly because this provider is not in the Plan's network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1500 deductible which applies to out-of-network services.  
 
You received these services from an out-of-network provider. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1500 deductible which applies to out-of-network services. This cost 
sharing is a contractual obligation that had not been met at the time the out-of-network pulmonology visits 
were received on March 8, 2021 to May 5, 2021. Therefore, we decided that the Plan does not have to waive 
the deductible for office visits with an out-of-network pulmonologist you had on March 8, 2021, and March 5, 
2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 75726. We decided that the Plan does not have to pay for CPT 
99153.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
 
 We decided that the Plan has to pay for 75726.  
 
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 75726 is "Angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation." 
 
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 for CPT 75726. Our reviewer says that that the medical 
records do support the use of procedure code 75726 with the use of modifier -59. The records support this with 
the description of using the microcoils to view mesenteric branches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
75726.  
 
We also decided that the Plan does not have to pay for 99153. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
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 for CPT 99153. Our reviewer says that the medical 
records do not support the use of CPT 99153 in this case. The provider did not signify that the additional 
documentation for the additional sedation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99153 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99153. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
March 20, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment applied was 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 $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 
an emergency room visit provided from March 20, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on February 2, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim was appropriately billed and the diagnosis 
codes are correct and payable. The Plan denied your request. The Plan says the diagnosis is inconsistent with 
the procedure. 
 
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 00170 is "Anesthesia for intraoral procedures, including 
biopsy; not otherwise specified." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, there are no intra-
operative anesthesia records submitted for any of the procedures performed.  It is likely that anesthesia CPT 
code 00170 is being appropriately billed for the dental procedures performed on this patient with Down 
syndrome. However, there is no way to verify this without anesthesia records. There is no documentation of the 
anesthesia start time or end-time or any documentation of each procedure start and end-time. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the referring provider ordered the test. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 radiology services provided on March 4, 2022, 
by an out-of-network (OON) provider.
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 18, 
2022. 
 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 March 18, 2022.
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 27, 
2022. 
 
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 March 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (49652, 49568) provided February 
11, 2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provided is not eligible for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (49652, 
49568) provided February 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this is being incorrectly. The Plan denied your 
request. The Plan says prior authorization was not obtained for these services. 
 
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 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service February 
17, 2022. 
 
You asked the Plan to pay for procedure code 71045-26. You say that this is a distinct service and should be 
paid. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into payment for 
code 32555-RT. 
 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 
71045-26 is a column II code to column I code 32555-RT. 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 71045-26 billed for date of service 
February 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 2, 
2022. 
 
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 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 March 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 17, 
2022. 
 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 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 January 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. The Plan denied your request. The Plan says the 
facet joint interventions are not medically necessary. 
 
The Plan follows Medicare 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 facet joint interventions. Our reviewer 
says that the facet joint interventions are not medically necessary. Our physician reviewer found repeat 
diagnostic blocks are not necessary as you had successful RFA just 16 months ago and would be a reasonable 
candidate for repeat RFA. The request for diagnostic blocks is considered not medically reasonable or 
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 facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you initially received an EOB stating 
you had no responsibility. 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 $130 
copayment for diagnostic radiology services in a provider's office or freestanding radiology center.  
 
You have been asked to pay a $130 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the abdomen and pelvis provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
27, 2022. 
 
You asked the Plan to pay for procedure code 70450-26. You say that this claim was denied as a duplicate in 
error. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment for 
code 70496-26. 
 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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
February 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health services provided 
from February 1, 2022, to April 19, 2022. 
 
You asked the Plan to waive the copayments for the outpatient mental health services. You say that you believe 
these copayments are too high. You said that you only see the provider for 15 minutes to maintain your 
medications. The Plan denied your request. The Plan says you were charged these copayments 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 $40 
copayment per visit for outpatient mental health care.  
 
 
 
 
 
 You have been asked to pay a $40 copayment per visit for the outpatient mental health services. These 
copayments apply regardless of the length of these visits. 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 outpatient mental health services provided from February 1, 2022, to April 19, 2022.