Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152-59 provided on August 4, 2022. 
 
You asked the Plan to pay for procedure code 99152-59. You say that the medical records support the use of 
modifier 59 with procedure code 99152. The Plan denied your request. The Plan says the medical records do 
not support the use of modifier 59 with procedure code 99152. 
 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 99152 is a column II code to column I code 45378 and 43239; 
however, 99152 was billed with a modifier.  
 
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 procedure code 99152-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with procedure code 99152. Our reviewer found the 
documentation submitted was reviewed, and the records do not support the use of modifier 59 with procedure 
code 99152. Procedure report describes colonoscopy screening with "conscious sedation".  In this case, 
modifier 59 is inappropriate to report for this service. A more appropriate HCPCS code would be reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99152-59 provided on August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 23, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you don't agree with the 
copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
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 $150 
copayment for each separate Medicare-covered ambulance service. 
 
You have been asked to pay a $150 copayment for the ambulance services. This item/service 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 the ambulance 
services provided on October 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
31, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you say you cannot 
afford to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room visit. This item/service 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 copayment for an emergency room visit 
provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital care (procedure codes 71046 and 99223) provided to the 
enrollee on April 15, 2022. 
 
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 that the documentation does not support this level of care. 
 
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 
the denied codes is: 
 
CPT 71046: 
 
Radiologic examination, chest; 2 views 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
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 medically reasonable or necessary. Our reviewer found that a portable chest x-ray - CPT 71046 - 
was done on 4/15/22, and the report is documented in the records. Additionally, CPT 99223 - an inpatient 
comprehensive consultation was done by the cardiologist. This consult was done by a specialist who was not 
the admitting doctor and thus complies with the rules for reimbursement. The comprehensive level of care is 
supported by the documentation of the physical exam and the evaluation of many emergent imaging tests done 
on the patient that morning. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
hospital care (procedure codes 71046 and 99223) provided to the enrollee on April 15, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network endoscopy provided on June 
13, 2022. 
 
You asked the Plan to waive the copayment for an in-network endoscopy. You say that this was supposed to be 
a screening test and not diagnostic. The Plan denied your request. The Plan says this cost sharing was charged 
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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $225 copayment for an in-network endoscopy. This item/service falls within the 
outpatient surgery, including 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 copayment for an in-network endoscopy 
provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 
26, 2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that this visit should be covered 
in full. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for each Medicare-covered urgent care facility visit. 
 
You have been asked to pay a $45 copayment for the urgent care visit. This item/service 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 the urgent 
care visit provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist visit services provided by an 
out-of-network provider on September 8, 2022. 
 
You asked the Plan to waive the deductible for the specialist visit services. You say that you were not told that 
this provider was out-of-network. The Plan denied your request. The Plan says this cost sharing was charged 
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 says that you must pay the full cost for 
most covered services until you have paid your $1500 deductible, and the deductible applies to all out-of-
network services besides urgent/emergent services, preventative services, and supplemental benefits. 
 
 
 
 
 
 You have been asked to pay a $244.54 deductible for the specialist visit services ($79.47 allowed amount + 
$100.06 allowed amount + $29.67 allowed amount + $35.34 = $244.54 deductible). The items or services you 
asked the Plan to waive the deductible for were provided by 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 
physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that 
had not been met at the time the specialist visit services were received on September 8, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for the specialist visit services provided by an out-
of-network provider on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on July 19, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you should not have a copayment 
for this visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for specialist visit. This item/service 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 specialist visit provided on July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interstim implant (code 64590). 
 
You asked the Plan to pre-approve Interstim implant. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that Interstim implants are only covered for certain 
indications. 
 
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 Interstim implant. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has overactive bladder, urinary retention, and fecal incontinence. The 
enrollee also has a stroke and history of cystocele, enterocele and rectocele repair in 2010. The records do not 
show that the enrollee is refractory to conventional therapy (documented behavioral, pharmacologic therapy). 
There is a voiding diary showing that the enrollee may have had first stage Interstim trial, but the diary does not 
show greater than 50% improvement in symptoms. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Interstim implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Interstim implant (code 64590).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring services provided on 
September 17, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring services. You say that the records attached 
support the services provided The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote physiologic 
monitoring services provided on September 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network podietry visit provided 
on June 14, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network podietry visit. You say that you called the 
office and was told this provider was in-network, and you should only have a $35 copayment. The Plan denied 
your request. The Plan says this cost sharing was charged 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 $65 
copayment for podiatry services. 
 
You have been asked to pay a $65 copayment for an out-of-network podietry visit. This item/service falls 
within the podiatry 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. You have been asked to pay $79.76 towards your combined annual plan out-of-pocket 
maximum. Therefore, we decided that the Plan does not have to waive the copayment for an out-of-network 
podietry visit provided on June 14, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a procedure to restore blood flow to blocked blood vessels of the 
right leg blockage (revascularization). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show that the right hip pain will be improved with this request. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation supports the medical necessity of the treatment in question.  While the 
performance of a conventional ankle brachial index (ABI) would be more helpful, there is satisfactory 
documentation that the patient has significant peripheral artery disease. The patient has a history of right 
common femoral artery occlusion that, according to the medical record, it is likely a complication from her 
previous procedures.  She has had subsequent atherectomy of the right common femoral artery and now has 
evidence of significant re-stenosis that could be related to her current symptoms. In addition to documentation 
that the patient has significant peripheral artery disease, there is documentation that the patient is having 
symptoms inhibiting her mobility. Additionally, there is a reference to resting pain that is possibly related to 
her peripheral artery disease. 
 
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 pre-
approve a procedure to restore blood flow to blocked blood vessels of the right leg blockage 
(revascularization).  
 
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 waive the copayment for a specialist office visit provided on 
September 02, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $15 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network duplex scan provided on 
September 19, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network duplex scan. You say that you thought this was 
a follow up and did not hvae any kind of copay. The Plan denied your request. The Plan says this cost sharing 
was charged 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for an in-network duplex scan. This item/service 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. The allowed amount of this service was $259.42, 
resulting in a coinsurance amount of $51.88 ($259.42 x 20% = $51.88). Therefore, we decided that the Plan 
does not have to waive the coinsurance for an in-network duplex scan provided on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on July 15, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged 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 
$256.43 deductible for Out of Pocket. 
 
You have been asked to pay a $256.43 deductible for an office visit. This item/service falls within the Out of 
Pocket 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 deductible for an office visit provided on July 
15, 2022.