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

 
We decided that the Plan does not have to pay for radiology services (70450) provided October 12, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service has a bundled relationship with another code billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
shares a bundled relationship with 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 radiology services (70450) provided October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
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. 
 
The test at issue in this appeal was 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 provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a surgeon on 
September 20, 2021. 
 
You asked the Plan to waive the copayment for the visit with a surgeon. You say that you do not believe this 
office visit was necessary. The Plan denied your request. The Plan says you were charged this copayment 
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 $40 
copayment for visits with a specialist.  
 
You have been asked to pay a $40 copayment for the visit with a surgeon. The visit with a surgeon falls within 
the visits with a specialist benefit category. This copayment applies regardless of the reason for the visit. 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 office visit you had with a surgeon on September 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (67500) provided July 16, 2021. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
  
We find that CPT code 67500 is not supported in the medical record. Specifically, the code billed is inclusive 
to another code billed (67028). Based on this information, we decided that Medicare rules for coverage of the 
injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (67500) 
provided July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the office visit provided by an out-of-
network (OON) family practice doctor  at an OON rural health clinic on September 24, 2021. 
 
You asked the Plan to reduce the cost sharing for the OON office visit. You say that you would have never 
used an OON provider because you cannot afford it.  You also said that this was an urgent care visit. The Plan 
denied your request. The Plan says the facility that billed this claim is not an urgent care facility. The Plan also 
stated that the provider that the enrollee saw is not a network provider with the Plan, so the OON cost sharing 
applied appropriately. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 50% coinsurance for out-of-network primary care services.  
 
The enrollee has been asked to pay 50% coinsurance for the OON office visit. The clinic where the member 
was seen is an out-of-network facility.  Although you claim that this was an urgent care visit, the medical 
records from this visit show that the visit was for shoulder pain that had been worsening over the course of the 
week.  Your contract says that out-of-network urgent care is covered when network providers are temporarily 
unavailable or inaccessible.  You have made no argument that Plan providers were unavailable or inaccessible. 
According to the records, this visit occurred during normal business hours (3:57 pm) on a weekday (a Friday), 
so presumably Plan providers could have been available or accessible. No evidence was provided to the 
contrary.  This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to reduce the cost sharing for the office visit provided by an 
out-of-network (OON) family practice doctor  at an OON rural health clinic on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00140) provided April 29, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed cannot be paid. 
 
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 00140 is not supported in the medical record. Specifically, the anesthesia code billed 
does not crosswalk with the primary surgical procedure billed (66984). Code 00142 is more appropriate for this 
procedure. 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 anesthesia services (00140) 
provided April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Gammaplex injection (J1557) provided on September 1, 
2021. 
 
You asked the Plan to pay for a Gammaplex injection. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that limited diagnosis codes support the medical 
necessity of Intravenous Immunoglobulin (IVIG) services including Gammaplex injections (J1557). 
 
We looked at the file and Medicare rules. The billed diagnosis codes, D804, R768, K9289, G629, M064, and 
R894, do not support medical necessity. Based on this information, we decided that Medicare rules for 
coverage of a Gammaplex injection have not been met. Therefore, we decided that the Plan does not have to 
pay for a Gammaplex injection (J1557) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided on February 19, 2021. 
 
You asked the Plan to pay for code 99232. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 denied payment for code 99232 provided on February 19, 2021, stating 
that the same code and date of service were already paid for on another claim. However, the Plan provided no 
claims showing that code 99232 for date of service, February 19, 2021, was paid for by the Plan. We find that 
the Plan has not substantiated their reasoning for the denial of payment. Therefore, we decided that the Plan has 
to pay for the subsequent hospital care (99232) provided on February 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 83789 is not supported in the medical record. Specifically, CPT code 83789 is included 
in CPT code 80307 which was already approved. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (83789) provided July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Strapping; Unna boot (29580) provided on August 31, 
2021. 
 
You asked the Plan to pay for code 29580. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29580 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
29580 have not been met. Therefore, we decided that the Plan does not have to pay for the Strapping; Unna 
boot (29580) provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Rhytidectomy (15824). 
 
You asked the Plan to pre-approve the Rhytidectomy. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Cosmetic surgery or expenses incurred in connection 
with such surgery, for the sole purpose of improving ones appearance, 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 the Rhytidectomy. Our reviewer says 
that this procedure is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has gender dysphoria. The record does not indicate the presence of functional impairment as a result of 
a disease state. This procedure is generally considered cosmetic. The elements of the coverage criteria are not 
satisfied.  
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 Rhytidectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Rhytidectomy (15824).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit you had on 
September 16, 2021. 
 
You asked the Plan to waive the copayment for the primary care visit. You say that there should not be a 
copayment for this visit.  You said that you went in for your annual visit, but during the visit you mentioned 
knee pain.  You said that you did not know there would be a copayment for this visit. The Plan denied your 
request. The Plan says you were charged this copayment 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 primary care visits.   
The Plan contract says that you pay $0 for an annual physical.  However, if you receive services that address a 
medical condition during the same office visit, additional cost share may apply.  That was the case here.  
Because this office visits also addressed your complaints of knee pain, separate cost sharing applies. You have 
been asked to pay a $10 copayment for the primary care visit. 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 primary care office visit you had on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on September 17, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that this lab work was ordered during 
your annual wellness visit and you weren't informed about a copayment. The Plan denied your request. The 
Plan says you were charged this copayment 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 lab services.  
 
You have been asked to pay a $10 copayment for the lab services. Your contract explicitly states that an annual 
wellness visit does not include lab services, so separate cost sharing can apply. 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. Please note that this decision is limited to the cost 
sharing charged for the lab services.  If you wish to appeal any other services, please contact the Plan directly. Therefore, we decided that the Plan does not have to waive the copayment for lab services you received on 
September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided March 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SelectMDx is covered in males with previous 
negative prostate biopsy who are being considered for repeat biopsy. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. There is no record of a previous negative biopsy. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81479) provided March 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit (99212) and an x-ray examination of the wrist 
(73100) provided on September 30, 2021. 
 
You asked the Plan to pay for a specialist office visit and an x-ray examination of the wrist. You say that it did 
not make sense for you to return 1400 miles to your home state for a follow-up when you had seen the 
orthopedic physician where you were staying, and your plans were not to return to your home state until later in 
the season. The Plan denied your request. The Plan says that they denied coverage for this service because the 
provider is out-of-network. The Plan also says that your benefit plan does not cover services by out of network 
providers except in emergencies and other rare situations when the Plan has pre-authorized out-of-network use. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 a specialist office visit and an x-ray 
examination of the wrist. Our reviewer says that this service meets criteria. Our physician reviewer found that 
in this case, the record indicates that the enrollee suffered a distal radius fracture while out of the coverage area. 
The record indicates that the enrollee was still out of area when she required a follow up appointment. The 
injury was unforeseeable, and the care was medically necessary at the time. Having to delay the service until 
she returned to the coverage area was not reasonable. The elements of the coverage criteria are satisfied.  The 
requested service is  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 specialist office visit and an x-ray examination of the wrist have been met. 
Therefore, we decided that the Plan has to pay for a specialist office visit (99212) and an x-ray examination of 
the wrist (73100) provided on September 30, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the SNF services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you appear to have reached a 
plateau in function.  Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition.  Your needs may be met at a lower level of care. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital services 
you received from April 29, 2021, to May 10, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you 
are appealing this copayment. You did not provide an argument with your appeal request. The Plan denied your 
request. The Plan says you were charged this copayment correctly. The Plan says that you were in a 
rehabilitation hospital, not a skilled nursing facility. 
 
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 $250 
copayment per day for days 1-7 (up to a maximum of $1750 per admission) for inpatient hospital care.  
 Records show that you were in an inpatient rehabilitation hospital for 11 days. You were charged a $250 
copayment per day for each of the first 7 days, for a total of $1750. This stay was broken into two claims- one 
where you are being charged $1000 of the total copayment, and one where you are being charged the remaining 
$750 of the copayment.  This decision is limited to the claim with the $1000 portion of the total copayment. 
This copayment was assessed in accordance with your contract. 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 inpatient rehabilitation hospital services you received from April 29, 2021, to May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on October 8, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay for lab 
work before. The Plan denied your request. The Plan says you were charged this copayment correctly.  The 
Plan says that because the allowed amount for this lab service ($5.18) is less than your copayment obligation, 
you are responsible for the full allowed 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 $10 
copayment for lab services.  
 
 You have been asked to pay a $10 copayment for the lab services. 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 lab services you received on October 8, 2021.