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

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service November 
27, 2021. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service November 27, 
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not support that 
services in the home with home health care or in a long-term care facility on a part time basis are not 
appropriate in this case. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of benign lesions (17110) provided on March 
9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the destruction of benign lesions. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says the original claim denial was for not meeting Medicare 
criteria, but upon reconsideration, the Plan says that the provider is out-of-network. The Plan determined that 
the enrollee did not get a referral for services and no medical necessity could be established which would 
require coverage of the 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 the destruction of benign lesions (17110) provided 
on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on May 11, 2021, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 outpatient surgery provided on March 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an (MRI) provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you do not agree with the copayment 
assessed. You say you paid $194.41 but when the claim was reprocessed to show a copayment of $200, you are 
being charged the difference. 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 $200 
copayment for advanced radiology services (CT, MRI, MRA, and SPECT scans). 
 
You have been asked to pay a $200 copayment for an MRI. An MRI 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 an (MRI) provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic injection, blood count, and vitamin B-12 
injection provided on March 23, 2022, by an OON provider. 
 
You asked the Plan to pay for a therapeutic injection, blood count, and vitamin B-12 injection. You say that 
you are asking for reconsideration of coverage for these services until in-network status is obtained. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
 
 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 injection, blood count, and vitamin 
B-12 injection provided on March 23, 2022, by an OON provider.
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 the enrollee needs SNF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirements 
for approval. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on May 25, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $115 
copayment for Medicare-covered emergency room visits. Emergency care refers to services that are furnished 
by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition. 
 
You have been asked to pay a $115 copayment for emergency room services. Emergency room services fall 
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 emergency 
room services on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute knee scooter (E0118). 
 
You asked the Plan to pre-approve a crutch substitute knee scooter. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitute knee scooter devices. Based on this information, we decided that Medicare rules for coverage of a 
crutch substitute knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crutch substitute knee scooter (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity revascularization procedure. 
 
You asked the Plan to pre-approve a lower extremity revascularization procedure. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a lower extremity revascularization 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has 
peripheral vascular disease with claudication. The record indicates that the enrollee has had a femoral popliteal 
bypass that occluded. The record provided is insufficient to demonstrate the medical necessity of iliac 
revascularization. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lower extremity revascularization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity revascularization procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 20, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 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 76700 
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 76700 billed for date of service May 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on August 16, 
2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you feel that you 
should not owe because you were not treated by a doctor. The Plan denied your request. The Plan says the cost 
sharing 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 $90 
copayment for each emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
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 emergency 
room services on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a TENS unit provided on May 17, 2022. 
 
You asked the Plan to waive the coinsurance for a TENS unit. You say that this item didn't work so you sent it 
back. The Plan denied your request. The Plan says you were charged this cost sharing 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$47.50 resulting in a $9.50 coinsurance ($47.50 x 20% = $9.50). 
 
You have been asked to pay a $9.50 coinsurance for a TENS unit. A TENS unit 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 TENS unit provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power lift recliner provided on April 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for power lift recliner. You say that you are requesting reimbursement for the power 
lift chair. The Plan denied your request. The Plan says when criteria met only lift mechanism is covered. 
Chair/mechanism are not covered for non-Medicare certified providers. 
 
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 power lift recliner provided on April 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) evaluation provided on 
January 6, 2022, billed with code 99284. 
 
You asked the Plan to pay for the ED evaluation as billed. You say that the billed CPT code was most 
appropriate for the rendered services. The Plan denied your request. The Plan says the billed level of service for 
this code was adjusted to one that is consistent with the information on the claim. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and medical decision making of moderate 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 presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other 
qualified health care professionals but do not pose an immediate significant threat to life or physiologic 
function. 
 
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 pay for the ED evaluation as billed. Our reviewer 
says that the documentation does not support the use of code 99284 for the rendered services. Our reviewer 
found the enrollee was a male with a history of stroke who was sent to the ED by his daughter due to him not 
speaking. He was fully evaluated and discharged. No acute issues were identified. The review has determined 
that the Plan was correct to down code CPT code 99284 to CPT 99283. 
 
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 ED evaluation as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the emergency department (ED) evaluation provided on January 6, 2022, billed 
with code 99284.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from November 
19, 2021, to March 31, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that the staff at the facility never 
told you that there was a copayment for these visits, and never asked for one. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a total $1397.48 copayment for physical therapy. Physical 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 copayments for 
physical therapy provided from November 19, 2021, to March 31, 2022.  
 Your complaint about the office not notifying you of copayments or collecting them is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 17, 
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 [insert column I 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. In this case, we have confirmed that code 70450 
is a column II code to column I code [insert column I code]. 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 
April 17, 2022.