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

 
We decided that the Plan does not have to waive the copayment for an ambulatory continuous glucose 
monitoring provided on December 1, 2021. 
 
You asked the Plan to waive the copayment for the ambulatory continuous glucose monitoring. You say that 
you were told there was a copayment because this service fell under advance imaging, and it should not. You 
would like for the service to be covered with no copayment. The Plan denied your request. The Plan says the 
claim was processed correctly, and 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 $60 
copayment for each covered diagnostic procedure or test at a network doctor's office. The total amount allowed 
was $41.08 which is less than the copayment amount of $60. Therefore, only $41.08 was charged as a 
copayment. 
 
You have been asked to pay a $41.08 copayment for the ambulatory continuous glucose monitoring. The 
ambulatory continuous glucose monitoring 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 waive the copayment for an ambulatory continuous 
glucose monitoring provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the speech therapy provided in a hospital 
outpatient department on November 11, 2021. 
 
You asked the Plan to waive the copayment for the speech therapy. You say that this therapy on date of service 
November 11, 2021, was canceled and you should not be billed for it. 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 a $30 
copay for each Medicare-covered speech-language therapy visit provided in an outpatient setting.  
 
 You have been asked to pay a $30 copay for the speech therapy. The speech therapy falls within the 
Outpatient Rehabilitation 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 speech therapy provided in a hospital outpatient department on November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve plastic 
surgery to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955-26, 95885-26, and 95908-26 billed 
for date of service June 18, 2021. 
 
You asked the Plan to pay for procedure codes 95955-26, 95885-26, and 95908-26. You say that you have 
provided medical records to support payment of these codes. The Plan denied your request. The Plan says these 
codes are not supported in the medical records. 
 
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 95955 is electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 
code 95908 is nerve conduction studies; 3-4 studies. 
 
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 codes 95955-26, 95885-26, and 95908-26. Our 
reviewer says that these procedure codes are not supported in the medical record. Our reviewer found regarding 
code 95955, the technical report describes a continuous electroencephalogram.  This procedure is inclusive to 
the primary intraoperative monitoring code. Regarding code 95885, the technical report does not support the 
criteria for this procedure.  This procedure is performed with nerve conduction studies.  In this case, nerve 
conduction studies cannot be verified, and therefore this procedure would not be covered. Regarding code 
95908, the technical report describes pedicle screw stimulation, which would not be reported with nerve 
conduction studies which measure amplitude and latency/velocity. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95955-26, 95885-26, and 95908-26 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95955-26, 95885-26, and 95908-
26 billed for date of service June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for eye surgery performed on November 16, 
2021. 
 
You asked the Plan to waive the coinsurance for the eye surgery. You say that you do not agree with the 
charges. The Plan denied your request. The Plan says the correct coinsurance 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 50% 
coinsurance for surgery with an out-of-network (OON) provider. 
 
Procedure Allowed Amount 50% Coinsurance 
Exchange of Lens Prosthesis $906.38 $453.19 
Repair of Iris and Lens Tissue $262.02 $131.01 
Total:  $584.20 
  
You have been asked to pay $584.20, which is 50% of the allowed amount for the eye surgery. The eye surgery 
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 coinsurance for eye surgery 
performed on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Mammography on January 6, 2022. 
 
You asked the Plan to waive the copayment for a Mammography. You say that the provider is charging you for 
an exam you received when there is nothing wrong with you. The Plan denied your request. The Plan says the 
copayment you are being charged 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 $20 
copayment for Mammography.  
 
You have been asked to pay a $20 copayment for a Mammography. A Mammography 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 Mammography on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99214) provided on September 30, 2021. 
 
You asked the Plan to pay for code 99214. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 
is a column II code to column I code 99204. 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 the outpatient visit (99214) provided on September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Echocardiography (93308) provided on October 5, 2021. 
 
You asked the Plan to pay for code 93308. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93308 
is a column II code to column I code 33361. 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 the Echocardiography (93308) provided on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest (71045, R0070, Q0092) provided on 
November 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray of the chest. You say that the service was performed on a non-skilled 
patient in a nursing home and does not require authorization. The Plan denied your request. The Plan says the 
rendering provider is non-participating and the referring provider in non-participating. The Plan also says that 
this was denied for no preauthorization. 
 
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 x-ray of the chest (71045, R0070, Q0092) 
provided on November 19, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on May 13, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is included in another billed 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. 
 
Per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This means that the payment for 
99072 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of additional supplies, materials, and clinical staff time have not been 
met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical 
staff time (99072) provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance. 
 
You asked the Plan to pre-approve an oral appliance. You say that the requested oral appliance is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
oral appliance. 
 
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 an oral appliance. Our reviewer says 
that the enrollee does not meet criteria for the requested oral appliance. Our physician reviewer found a 
mandibular advancement device (MAD) is considered not medically necessary because coverage criteria have 
not been met. This enrollee has obstructive sleep apnea (OSA) with a respiratory disturbance index (RDI) of 
22, which meets Medicare criteria for a MAD.  But the enrollee's most recent clinical encounter was more than 
a year ago, and none of the clinical encounters have included a detailed upper airway examination.  Aside from 
the handwritten note on December 1, 2021, it does not appear there has been an evaluation of whether the 
enrollee has actually used CPAP, or whether the intolerance can be addressed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an oral appliance.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic procedure provided on March 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic procedure. You say that a previous claim for the same procedure 
was partially paid and you would like this claim to be paid too. The Plan denied your request. The Plan says the 
previous claim was paid due to an administrative error. The rendering provider is an out-of-network provider 
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 a therapeutic procedure provided on March 31, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided September 22, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says 1 unit of this service was already paid. Additional units are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 70450 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 70450. Based on this information, we decided that Medicare rules for coverage of 
the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (70450) provided September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not safe at home. The Plan denied your 
request. The Plan says you do not require daily services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the submitted records does not show evidence 
of complex wound care, new enteral feedings, or other skilled nursing needs. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. As a practical matter, 
you do not require the services on an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services performed on 
November 14, 2021. 
 
You asked the Plan to waive the copayment for the advanced imaging services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on 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 $225 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $225 copayment for advanced imaging services. Advanced imaging services fall 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for advanced imaging services performed on November 14, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 15002-58. We decided that the Plan does not have to 
pay for procedure code 29125-58-59.  
 You asked the Plan to pay for procedure code 15002-58 procedure codes 15002-58 and 29125-58-59. You say 
that the records support payment for these services.  The Plan says that for code 15002-58, this code is not 
supported by the medical record.  The Plan also says that code 29125-58-59 is inclusive to another billed code. 
 
We decided that the Plan has to pay for procedure code 15002-58 .  
 
We sent this case to a coding reviewer.  That reviewer determined that code 15002-58 is supported in the 
medical record.  Specifically, the definition of code 15002 is surgical preparation or creation of recipient site by 
excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area in infants and children. The operative report 
describes preparation of an open wound, for which a skin graft was applied. To cite the report the patient was 
then prepped and draped in the standard sterile fashion and a timeout was performed. The left forearm wound 
measured 8 x 6 cm2. Sharp excisional wound preparation was performed with a sharp curette to remove skin 
and subcutaneous tissue to prepare the wound for closure.   
 
 Therefore, we decided that the Plan has to pay for procedure code 15002-58 .  
 
We also decided that the Plan does not have to pay for procedure code 29125-58-59. 
 
 Our coding reviewer found that this procedure would be inclusive to the wound care and should not be 
reported separately. Therefore, we decided that the Plan does not have to pay for procedure code 29125-58-59. 
 
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 waive the copayment for a breast MRI (77049) provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the breast MRI. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $100 copayment for the breast MRI. MRIs fall within the Outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a breast MRI (77049) provided on December 8, 2021.