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

 
We decided that the Plan has to pay for injection services provided to the enrollee on January 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 20550 (4 units) remains not supported. 
 
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 20550 is "Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure note indicated that she 
was provided with trigger point injection of the right erector spinae and left erector spinae under ultrasound 
guidance as well as aponeurosis injection of the right and left thoracolumbar fascia under ultrasound guidance. 
A 22gg needle was advanced toward the right erector spinae and left erector spinae. Then 2ccs of 1% 
Lidocaine and 2ccs of plasma and platelets were injected at each region of maximal tenderness with a total of 
4ccs injected. Then a 22gg needle was advanced towards the intended areas of the injection, then 1% 
Lidocaine was injected at each region of maximal tenderness in the right thoracolumbar fascia and left 
thoracolumbar fascia sheath. Then 1cc of 1% lidocaine and 2ccs of plasma and platelets were slowly injected 
into the right thoracolumbar fascia and left thoracolumbar fascia, with a total of 3ccs. Therefore, the records 
do support that CPT 20550- Injection(s): single tendon sheath or ligament, aponeurosis (e.g., plantar fascia)- 
was rendered in this case.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
injection services provided to the enrollee on January 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheter supplies provided on April 8, 
2022. 
 
You asked the Plan to waive the coinsurance for catheter supplies. You say that you should not be responsible 
for this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was 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% 
coinsurance for Durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$1152 resulting in a coinsurance amount of $230.40 ($1152 x 20% = $230.40). 
 
You have been asked to pay a $230.40 coinsurance for catheter supplies. catheter 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 coinsurance for catheter supplies provided on April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Part B drugs regadenoson and sestamibi 
provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for the Part B drugs. You say that you have kidney failure and are 
not able to use any type of contrast. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 Part B drugs.  
 
You have been asked to pay a $89.06 coinsurance for Part B drugs ($445.30 the allowed amount for the drugs x 
20% = $89.06). Part B drugs 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 copayment for the Part B drugs regadenoson and sestamibi provided on February 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on January 27, 
2022, and March 3, 2022. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you do not understand why the 
manual manipulation was denied when it says it is a covered service in the Evidence of Coverage. The Plan 
denied your request. The Plan says submitted medical records show that the service was applied to the 
shoulder, neck, and the middle of the back, not the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  The medical records provided show that the chiropractic manipulative treatment was not performed to treat the 
spine and there was no subluxation documented. Therefore, we decided that the Plan does not have to pay for 
chiropractic manipulative treatment provided on January 27, 2022, and March 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided 
from June 11, 2021, to September 7, 2021. 
 
You asked the Plan to waive the copayment for PT services. You say that you would like the plan to investigate 
these claims. The Plan denied your request. The Plan says the copayment amount 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 a $20 
copayment per provider, per date of service for the Keystone 65 Focus Rx plan. 
 
You have been asked to pay $100 ($20 copay x 5 visits) for the PT services. The PT services fall 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 
physical therapy (PT) services provided from June 11, 2021, to September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says they have an in-network provider that can provide the service, and they 
are accepting new patients and has an appointment on September 7th and is within the allowable distance from 
you. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you were unaware that prior authorization 
was required when services are rendered by an out-of-network provider. The Plan denied your request. The 
Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. he 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 anesthesia services provided on March 9, 2022, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for hospice care provided to the enrollee on January 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the day of death is not payable. 
 
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. The plan has not forwarded a valid denial in this case. The denial is based on 
state guidelines, rather than Medicare federal guidelines. Additionally, the cited DHCS - All Plan Letter (APL) 
13-014 does not actually state that hospice care on the date of death is not covered. It only states that if the 
enrollee is inpatient on the day of death, then the inpatient rate is paid. Though this document does not specify 
coverage rules for hospice care provided on the date of death, this does not imply that hospice care does not 
qualify for coverage on the date of death. There is no valid citation provided to support that coverage of this 
date is not the Plan's responsibility. Therefore, we decided that the Plan has to pay for hospice care provided to 
the enrollee on January 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01924-GZ billed for date of service October 
12, 2021. 
 
You asked the Plan to pay for code 01924-GZ. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says this service is not covered as billed. The Plan must follow 
Medicare rules. Medicare rules say that all claim lines billed with a GZ modifier will be denied.  You billed 
code 01924 with a GZ modifier. Therefore, we decided that the Plan does not have to pay for procedure code 
01924-GZ billed for date of service October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 13, 
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 for date of service March 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 22, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the medical documentation does not substantiate the medical necessity requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van) were contraindicated for 
this patient. The documentation does not support that the patient needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The 
documentation does not support that the ambulance transport on 2/22/22 was medically reasonable and 
necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and advance care planning 
provided on February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care, and advance care planning provided. You say 
that your doctor is a hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
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 subsequent nursing facility care, and advance care 
planning provided on February 11, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 3, 
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 for date of service February 3, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided to the enrollee 
on January 22, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee was found standing with a walker, and vital signs were stable. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee was transported via ambulance from the hospital to the nursing home following treatment in the 
hospital for COVID-19. No treatment was administered during transport. The documentation does not support 
that other means of transport (such as stretcher van, wheelchair van, taxi) were contraindicated for this member 
on 1/22/22. The documentation does support that the enrollee needed the expertise, services and lifesaving and 
life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on 1/22/22. The 
documentation does not support that the ambulance transport on 1/22/22 was medically reasonable and 
necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation services provided to the enrollee on January 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a surgical shoulder arthroscopy (procedure code 29823) provided to the 
enrollee on November 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the requested service code is not substantiated by the clinical documentation in the medical 
records submitted for review. 
 
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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were supported by the medical records. Our reviewer found that the procedure notes the following 
structures were debrided during the procedure: in the glenohumeral joint: synovium, rotator cuff, and labrum; 
and in the subacromial space: rotator cuff, bursa, CA ligament and bone. Therefore, the records do support that 
29823- arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (e.g., humeral 
bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor 
complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial 
bursa, foreign body[ies])- was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for a 
surgical shoulder arthroscopy (procedure code 29823) provided to the enrollee on November 18, 2021.  
 
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 pay for procedure code 70450 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 for date of service December 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 12, 
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 for date of service February 12, 
2022.