Persius/hicric huggingface dataset:
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 6, 
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 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for remote diabetic monitoring services 
(99457, 99458) provided on January 2, 2022. 
 
You asked the Plan to waive the coinsurance for the remote diabetic monitoring services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance 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 50% 
coinsurance for Diabetes self-management training, diabetic services, and supplies.  
 
 
  You have been asked to pay a 50% coinsurance for the out-of-network remote diabetic monitoring services. 
Remote diabetic monitoring services fall within the Diabetes self-management training, diabetic 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 coinsurance for remote diabetic 
monitoring services (99457, 99458) provided on January 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from May 12, 2021, through 
August 16, 2021. 
 
You asked the Plan to pay for physician's services. You say that you were under the impression the Plan would 
pay for these services and fill in the gaps from which Medicare does not provide.The Plan denied your request. 
The Plan says the services are from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided from May 12, 2021, through August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, each additional 30 minutes (99292) provided on 
January 21, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately and is supported 
in the medical record. The Plan denied your request. The Plan says 99292 is an add-on code for 99291. 99291 
was not billed for the date in question, therefore, the use of 99292 is inappropriate in this case. 
 
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each 
additional 30 minutes (List separately in addition to code for primary service). 
 
We have confirmed that code critical care is an add-on code and has not been billed with an appropriate 
primary procedure code by any provider for this enrollee on the date in question. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, each additional 30 minutes (99292) provided on January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a computed tomography (CT) Scan 
provided on February 11, 2022. 
 
You asked the Plan to waive the deductible for the CT scan. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the CT scan was received on February 11, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for a computed tomography (CT) Scan provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99204) and a spinal X-ray 
(72050) provided on September 15, 2021. 
 
You asked the Plan to pay for an office or other outpatient visit and a spinal X-ray. You say that the services at 
issue were a necessity for your care. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for an office or other outpatient visit and a spinal X-ray until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (99204) 
and a spinal X-ray (72050) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97010) provided March 4, 2022 to 
March 11, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for 
chiropractic services (97010) provided March 4, 2022 to March 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit, and the 
observation services provided from February 21, 2022, to February 22, 2022, and February 25, 2022. 
 
You asked the Plan to waive the copayments for an emergency room visit and the observation services. You 
say that the cost of the copayments is too high, and you would like them waived. The Plan denied your request. 
The Plan says the proper copayments were applied for the services that were rendered. 
 
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 Medicare-covered services. Cost sharing is waived if you are admitted to the hospital within 24 
hours of your emergency room visit, regardless of whether admitted as an inpatient or for outpatient 
observation services and a $350 copayment for Medicare-covered outpatient observation services.  You have been asked to pay a $90 copayment for an emergency room visit and a $350 copayment for the 
observation services. An emergency room visit falls within the Emergency care benefit category and 
observation services falls within the Outpatient hospital observation 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 an emergency room visit, and the observation services provided from February 21, 
2022, to February 22, 2022, and February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided 
on January 30, 2022. 
 
You asked the Plan to pay for supplies for a continuous glucose monitor. You say that the requested item was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the available medical records do not discuss the item at issue. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided on January 
30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7323). 
 
You asked the Plan to pre-approve Hyaluronan or derivative. You say that you would like this to be 
reconsidered for coverage. The Plan denied your request. The Plan says the notes do not show that the enrollee 
has tried and failed conservative treatment options such as exercise, physical therapy, bracing, or weight loss. 
The Plan also says that x-ray results were not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Hyaluronan or derivative. Our reviewer 
says that the elements of the coverage criteria are not satisfied, and the requested service cannot be 
recommended. Our physician reviewer found the record indicates that the enrollee has a diagnosis of knee pain 
attributed to osteoarthritis. The record provided does not include x-rays of the diagnosis. Our reviewer found 
that the record does not indicate that physical therapy and conservative therapy have been tried and failed or is 
contraindicated. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. Our physician reviewer also found that the Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan or derivative have not been met. 
 
  
 Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed on date of service March 10, 
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 on date of service March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
(U0003) provided on September 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are in disagreement on the decision 
made. You request reconsideration on the claim number mentioned with the attached supporting 
documentation. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 infectious agent detection by nucleic acid (DNA 
or RNA) (U0003) provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for insulin supplies (A4224, A4225) provided 
on February 11, 2022, and March 13, 2022. 
 
You asked the Plan to waive the copayment for the insulin supplies. 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the insulin supplies (total allowed is $690.79 x 20% = 
$138.16). Insulin supplies fall 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 copayment for insulin supplies (A4224, A4225) provided on 
February 11, 2022, and March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for botox injections provided on January 20, 
2022. 
 
You asked the Plan to waive the coinsurance for the botox injections. You say that when you switched plans 
you were told your injections would still be covered. The Plan denied your request. The Plan says the 
coinsurance was applied 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 all other drugs covered under Medicare Part B.  
 
You have been asked to pay $256.06 (allowed = $1,280.30 x 20%) for botox injections. The botox injections 
fall within the Medicare Part B prescription drugs 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 botox injections provided on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nerve conduction studies (95911) provided 
on January 7, 2022. 
 
You asked the Plan to waive the copayment for the nerve conduction studies. 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 $95 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $95 copayment for the nerve conduction studies. Nerve conduction studies 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 nerve conduction studies (95911) provided on January 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs 24-hour supervision due to safety 
concerns related to her memory issues and confusion, and the family is not able to provide this. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage. 
 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 a SNF 
admission is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does 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) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more physical therapy to regain 
full function. The Plan denied your request. The Plan says the information received does not show that the 
enrollee has completed his full course of care in the IRF. 
 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 
enrollee does not meet criteria for SNF care. Our physician reviewer found that the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does 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) admission and services.