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

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on May 1, 2022. 
 
You asked the Plan to pay for procedure code 81455. 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 the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81455 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81455) provided on May 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00811 provided on February 
11, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 00811 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; screening colonoscopy. 
 
We find that CPT code 00811 is not supported in the medical record. Specifically, this code was billed with an 
incorrect modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
coded 00811 provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 27, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the facility has a skilled nursing side and a 
rehab side. The enrollee was denied for the skilled nursing side but needs approval for the rehab side. The Plan 
denied your request. The Plan says that the clinical notes do not show that the enrollee needs daily skilled 
nursing care in a facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. in this case specific records or information was required to substantiate the plans 
denial. The required medical records was missing from the original file. A request for the medical records was 
sent to the health plan on October 07, 2022 with a due date of October 11, 2022 and a second request was sent 
October 13, 2022 with a due date of October 17, 2022. The requested provider in this case is also an in-network 
provider and the Plan is responsible for supplying medical records. In addition, the language of the denial 
indicates that medical records were used to make the decision.  As of the date of this letter, the plan has not 
submitted the required information. Therefore, we decided that the Plan has to pre-approve the skilled nursing 
facility (SNF) admission.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 97010 is considered bundled and 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 procedure code.  
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service May 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transportation 
provided to the enrollee on April 6, 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 the benefits were applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transportation provided to the enrollee on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visits provided on June 21, 2022, 
to July 01, 2022. 
 
You asked the Plan to waive the copayment for telehealth visits. You say that these were brief phone calls, and 
one of them was with a PA and not the doctor. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for telehealth visits. 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. ($10 x 2 visits = $20) Therefore, we decided that 
the Plan does not have to waive the copayment for telehealth visits provided on June 21, 2022, to July 01, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gadolinium-based magnetic resonance contrast agent 
injection coded A9579 provided on February 3, 2022. 
 
You asked the Plan to pay for the gadolinium-based magnetic resonance contrast agent injection. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 A9579 is injection, gadolinium-based magnetic 
resonance contrast agent, not otherwise specified (nos), per ml. 
 
 We find that CPT code A9579 is not supported in the medical record. Specifically, the documentation shows 
that multihance was administered. This means there is a more appropriate code to be billed for the services 
rendered. Based on this information, we decided that Medicare rules for coverage of the gadolinium-based 
magnetic resonance contrast agent injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the gadolinium-based magnetic resonance contrast agent injection coded A9579 provided on 
February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided February 9, 2022. 
 
You asked the Plan to pay for the PCR panel testing. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine polymerase chain reaction (PCR) panel testing provided February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the insulin pump and supplies provided on 
July 03, 2022. 
 
You asked the Plan to waive the coinsurance for the insulin pump and supplies. You say that you were not 
aware that you would be charged monthly. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the insulin pump and supplies. This item/service 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. The allowed amount for the insulin pump and 
supplies is $364.99, and the 20% coinsurance applied is $73.00. Therefore, we decided that the Plan does not 
have to waive the coinsurance for the insulin pump and supplies provided on July 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2022 to January 28, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2022 to January 28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided on March 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cochlear implant removal provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for a cochlear implant removal. You say that you should not have a 
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 $320 
copayment for outpatient surgery.  
 
You have been asked to pay $196.72, which is less than the original copayment of $320 for a cochlear implant 
removal. This item/service falls within the outpatient surgery 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 cochlear implant removal provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee arthroscopy. 
 
You asked the Plan to pre-approve right knee arthroscopy. 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 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 right knee arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for tear of the medial meniscus. The enrollee presented 
with refractory right knee pain and mechanical-type symptoms. The enrollee has attended physical therapy. 
The enrollee now has much sharper pain in the medial aspect of the knee. Exam reveals exquisite joint line 
discomfort and much more positive McMurrays test. However, the provided imaging demonstrates 
degenerative changes. The x-rays from April 19, 2022 noted moderate patellofemoral joint space narrowing 
bilaterally, which is most pronounced within the medial compartment bilaterally; mild narrowing of the medial 
tibiofemoral joint of the right knee. The magnetic resonance imaging from June 14, 2022 noted 
ricompartmental chondrosis and osteophytosis. The subjective-objective exam findings failed to demonstrate significant locking-type mechanical symptoms of the knee. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. 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 right knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right knee arthroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 82728, 83880, 84436, and 
80050 provided on October 19, 2021.  
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says there is no determination of how the member came to the servicing 
provider or whether the services are medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the documentation does not support how the enrollee came to the servicing 
provider or whether the services were medically necessary. The information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. This means that the documentation does not support that the 
laboratory testing at issue in this appeal was not requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 82728, 83880, 84436, and 80050 provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93318 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 93318. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93318 is bundled into payment for code 00567. 
 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 93318 
is a column II code to column I code 00567. 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 93318 billed for date of service May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
April 29, 2022, to May 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you want to appeal the 
copayment for inpatient hospital care. 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 $350 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 1 day, resulting 
in a copayment amount of $350.  
 
You have been asked to pay $350 copayment per day for days 1 to 5 for inpatient hospital care. This 
item/service falls within the inpatient hospital 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 the inpatient hospital care provided on April 29, 2022, to May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. 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 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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for impingement syndrome of the left shoulder. The 
enrollee presented with worsening left shoulder symptoms. The exam reveals the enrollee still has some pain 
with abduction against resistance. The enrollee still has positive impingement sign. The enrollee is tender to 
palpation over the acromioclavicular joint of both shoulders. However, detailed documentation is not evident 
regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. 
The documentation does corroborate previous conservative measures having been trialed. However, they are 
not indicated to be recent. With documentation indicating that the shoulder has become more painful over the 
last several months, it would be reasonable to proceed with conservative treatments prior to consideration for surgical procedure. Moreover, the magnetic resonance imaging dated August 3, 2022 notes mild to moderate 
acromioclavicular and mild glenohumeral degenerative changes (plausibly acting as significant pain 
generators). There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.