Persius/hicric huggingface dataset:
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 
13, 2021. 
 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 December 13, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay the copayment for a diagnostic ultrasound provided on 
December 2, 2021. 
 
You asked the Plan to pay the copayment for the diagnostic ultrasound. You say that this service should of 
been covered and the Plan should cover something. The Plan denied your request. The Plan says the contracted 
amount for this service is less than the copayment amount the enrollee is responsible for. Therefore, the proper 
copayment amount was applied. 
 
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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility. The total amount allowed was $71.11 which is less than the 
copayment amount of $160. Therefore, only $71.11 was charges as the copayment amount. 
 
  You have been asked to pay a $71.11 copayment for the diagnostic ultrasound. The diagnostic ultrasound falls 
within the Outpatient Diagnostic Test 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 pay the copayment for a diagnostic ultrasound provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the epidural steroid injections are 
medically necessary. The Plan denied your request. The Plan says the requested repeat epidural steroid 
injection is supported for either of the following: 1) the prior epidural injection provided at least 50% 
improvement in pain and/or function measured from baseline using the same scale for at least three months, or 
2) the initial injection did not provide relief, but there has been a re-evaluation and a change in the technique or 
medication will be used, and it has been 14 days since the initial injection was performed. The clinical 
information provided does not describe one of these and, therefore, the requested procedure is not indicated at 
this time 
 
The Plan follows Medicare 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 pre-approve epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically necessary. Our physician reviewer found the 
request exceeds utilization criteria of the Medicare NCD.  Therefore, the request is deemed not medically 
reasonable or 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department services (99285) 
and self-care/home management training (97535) provided from October 12, 2021, to December 6, 2021. 
 
You asked the Plan to waive the copayment for emergency department services and self-care/home 
management training. You say that you requested to be transferred to your hospital and should not be held 
responsible for the copayments. The Plan denied your request. The Plan says you were 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 $90 
copayment for Emergency Care. Your contract with the Plan also says that enrollees must pay a $40 copayment 
per provider, per day for occupational services for outpatient rehabilitation services.   
You have been asked to pay a $90 copayment for emergency department services for two visits, which is a total 
of $180 ($90 x 2 = $180). Emergency department services falls within the emergency care benefit category. 
You have also been asked to pay a $90 copayment, which is less than the $236.92 total copayment for self-
care/home management training. Self-care/home management training falls under 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 emergency department 
services (99285) and self-care/home management training (97535) provided from October 12, 2021, to 
December 6, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on 
September 10, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you met your maximum out-of-
pocket for the year. 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 $115 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 
 The record shows your MOOP had not been met at the time of your ultrasound on September 10, 2021. You 
have been asked to pay a $115 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ultrasound of the heart provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15-minute (97813) acupuncture, one or 
more needles, each additional 15 minutes (97814) provided October 29, 2021 and November 1, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that please reconsider the denial and process 
the submitted claim for payment. The Plan denied your request. The Plan says services were rendered by a non-
covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract specifically says that 
acupuncture must be provided by a legally qualified physician practicing within the scope of their license. The 
services were rendered by an acupuncturist, not a physician. Therefore, we decided that the Plan does not have 
to pay for acupuncture, initial 15-minute (97813) acupuncture, one or more needles, each additional 15 minutes 
(97814) provided October 29, 2021 and November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 5, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member 
has other insurance primary to the Plan and in order to process this claim, an Explanation of Benefits (EOB) 
from the primary insurance carrier is needed. 
 
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 tried to 
obtain the EOB, but it has not yet been received. As the secondary insurer, the Plan cannot be held responsible 
for the physician's services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs and 
administration provided from January 5, 2021, to March 16, 2021. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs and administration. You say that you 
were told these services would be covered. The Plan denied your request. The Plan says the coinsurance 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for chemotherapy drugs provided in an outpatient hospital setting.  
 
 Date(s) of Service Service Provided Allowed Amount Cost Sharing per 
EOC 
Your 
Responsibility 
January 5  
January 12, 2021 
Chemotherapy Drugs: 
Administration: 
$7,702.24 
$284.28 
20% coinsurance 
20% coinsurance 
$1,540.45 
$56.86 
February 2, 2021  
 
Chemotherapy Drugs: 
Administration: 
$7,702.24 
$284.28 
20% coinsurance 
20% coinsurance 
$1,540.45 
$56.86 
February 23, 2021 Chemotherapy Drugs: 
Administration: 
$7,702.24 
$284.28 
20% coinsurance 
20% coinsurance 
$1,540.45 
$56.86 
March 16, 2021 Chemotherapy Drugs: 
Administration: 
$7,702.24 
$284.28 
20% coinsurance 
20% coinsurance 
$1,540.45 
$56.86 
Total:    $6,389.24 
 
You have been asked to pay $6,389.24 coinsurance for the chemotherapy drugs and administration. The 
chemotherapy drugs and administration 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 the chemotherapy drugs and administration provided from 
January 5, 2021, to March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological testing (96131, 96136, 96137, 96130, 96131) 
provided from November 9, 2021, to November 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychological testing. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and there is 
not a referring provider. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 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 psychological testing (96131, 96136, 96137, 
96130, 96131) provided from November 9, 2021, to November 13, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
24, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you were 
misdiagnosed and the antibiotic treatment caused an allergic reaction and an ER visit. 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 $40 
copayment for each visit with a specialist.  
 
 
 You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's 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. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 31, 2020, to August 14, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
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 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 not supported by the medical records. Our reviewer found that the provider billed PDPM score 
KISE1. The "K" requires medical management and PT/OT function score of 10-23. The provider billed a score 
of 16 for PT/OT function score. The documentation is insufficient to support a PT/OT function score of 16. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 31, 2020, to August 
14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on November 8, 2021, and 
December 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you were not told the provider was not 
participating with the Plan and you have been covered in the past with the same provider. The Plan denied your 
request. The Plan says documentation was sent prior to the enrollee stating the provider was no longer a 
participate in the Plan's network. Therefore, the service was rendered by an out-of-network provider without 
prior authorization and there are in-network providers that can provide the same service to the enrollee. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visits provided on November 8, 2021, 
and December 7, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy sessions provided on July 16, 2021, to 
July 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy sessions. You say that you would like the claim to be 
reprocessed as an outpatient therapy claim and for it to be paid. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider and there was no approved prior authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy sessions provided on July 16, 
2021, to July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (code D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that ber has moderate bone 
loss with heavy calculus deposits. Bone loss is generalized horizontal and probing depths are 4-7mm with 
bleeding on probing indicating moderate to serve chronic periodontal disease The Plan denied your request. 
The Plan says the documentation did not demonstrate evidence of significant bone loss (2.5+ mm from the 
cemento-enamel junction) and/or radiographic root surface calculus on 4 or more teeth per quadrant. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing when the services are medically necessary and reasonable.  
 
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 periodontal scaling and root planing. 
Our reviewer says that the requested dental service is not medically necessary. Our physician reviewer found 
the supplied x-rays are of insufficient quality as to assess the level of bone loss of all teeth in the quadrants.   
 It would appear that the molar teeth do exhibit notable bone loss, however it is not possible to see the osseous 
level in the premolar teeth to assess the periodontal condition. It is clear that there is existing periodontal 
disease in all quadrants in the molar region, however it is not possible to determine that four of more teeth are 
involved in any one quadrant as required under code D4341.  A lesser code may be appropriate given the 
presence of at least 1-3 teeth in a quadrant showing notable bone loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing (code D4341).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482, 80307) provided on January 5, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 drug testing (G0482, 80307) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 3, 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
 We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on August 3, 2021.