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

 
We decided that the Plan does not have to pay for codes 27134 and 27507 provided on May 27, 2022. 
 
You asked the Plan to pay for codes 27134 and 27507. 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 27134 is revision of total hip arthroplasty; both 
components, with or without autograft or allograft. The CPT Code Manual definition of code 27507 is open 
treatment of femoral shaft fracture with plate/screws, with or without cerclage. 
 
We find that CPT codes 27134 and 27507 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a revision of total hip arthroplasty; both components, with or without 
autograft or allograft; therefore, code 27134 cannot be verified. The operative report did not include 
documentation of an open treatment of femoral shaft fracture with plate/screws, with or without cerclage; 
therefore, code 27507 cannot be verified. 
 Based on this information, we decided that Medicare rules for coverage of codes 27134 and 27507 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 27134 and 27507 provided on 
May 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided March 4, 
2022. 
 
You asked the Plan to pay for the emergency visit. You say that please see attached notes and medical records 
stating that this enrollee went into the emergency room and was seen by the emergency room physician for a 
medically necessary procedure. Please reprocess this claim and pay this procedure code. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 29, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided 
March 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan for 
placement of radiation therapy fields provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan for placement of radiation 
therapy fields. You say that you would appreciate reconsideration of full coverage for the image guided 
radiation therapy (77014). 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 $55 
copayment for each diagnostic radiology service, including, but not limited to CT Scans. 
 
You have been asked to pay a $55 copayment for computed tomography (CT) scan for placement of radiation 
therapy fields. This item/service falls within the each diagnostic radiology service, including, but not limited to 
CT Scans 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 computed tomography 
(CT) scan for placement of radiation therapy fields provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of radiation 
therapy (G6001). 
 You asked the Plan to pre-approve Image Guided Radiation Treatment (IGRT). You say that the requested 
IGRT is medically necessary. The Plan denied your request. The Plan says the request does not meet the 
Medicare or health plan coverage criteria. 
 
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 Image Guided Radiation Treatment 
(IGRT). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses 
daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT 
allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be 
reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used 
when critical structures are abutting or in close proximity to the target that is being treated to high doses. This 
situation does not apply to the enrollee for which the target lesion can be seen on the skin to assist in daily set 
up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for 
daily simple simulations and/or IGRT for a technology for which need has not been established by published 
data or supported by consensus guidelines is not necessary. The requested service is unfavorable as billing for 
daily IGRT or daily simulations (also requested in this case) which would not be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Image Guided Radiation Treatment (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of radiation therapy 
(G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a health center visit provided on July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a health center visit. You say that you were out of state and 
were told by the office that you were covered because you have Medicare. The Plan denied your request. The 
Plan says that there is no documentation that you were referred to this non-contracted provider by a contracted 
provider. The Plan also says that there is no indication of any attempt made to obtain a prior authorization for 
the out-of-network services. 
 
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 an office visit and a health center visit provided on 
July 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management. You say that the plan should pay for these 
services. The Plan denied your request. The Plan says authorization was not obtained before you received the 
services out-of-network. 
 
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. 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 visit (99213) provided on June 3, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on July 12, 2022. 
Additionally, we decided that the Plan does not have to waive the copayment for the x-ray exam of the cervical 
spine (72050) provided on July 13, 2022. 
 
You asked the Plan to pay for the office visit. Additionally, you asked the Plan to waive the copayment for the 
x-ray exam of the cervical spine.  You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your 
request. The Plan says the office visit is not a covered service by the Plan or by Medicare. Additionally, the 
copayment has been applied correctly to the Medicare-covered x-ray provided.  
 
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.  
 
Additionally, 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 $110 copayment for Medicare-covered x-rays performed at an in-network hospital facility.    
 
The rules say that the only covered chiropractic service is manual manipulation of the spine. The service at 
issue is not manual manipulation of the spine. Additionally, the Plan contract says that enrollees must pay a 
$110 copayment for Medicare-covered x-rays performed at an in-network hospital facility. You have been 
asked to pay $106.88 for the Medicare-covered x-ray provided. This is the Plans allowed amount for this 
service, which is less than the applicable copayment. Therefore, we decided that the Plan does not have to pay 
for the office visit (99202) provided on July 12, 2022. Additionally, we decided that the Plan does not have to 
waive the copayment for the x-ray exam of the cervical spine (72050) provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 5, 2022. 
 
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 the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an offset axle for an approved power wheelchair 
(K0108). 
 
You asked the Plan to pre-approve the offset axle. You say that the axle is medically necessary. The Plan 
denied your request. The Plan says this type of axle does not meet the definition of DME and is not primarily 
for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an offset axle for an approved power wheelchair (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the CS modifier is accepted for specific 
procedure codes only. 
 
We looked at the file and Medicare rules. Procedure code 87635 was billed with the CS modifier. This modifier 
is not approved for billing with this code. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve DME. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says care that the enrollee receives from out-of-network providers will not be covered 
unless the care meets one of the three exceptions described in Section 1.2 of this chapter. For information about 
getting out-of-network care when the enrollee has a medical emergency or urgent need for care, please see 
Section 3 in this chapter. 
 
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 
durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic ultrasound rendered on June 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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, an abdominal aortic ultrasound, 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 abdominal aortic ultrasound rendered on June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemotherapy drugs provided February 23, 
2022. 
 
You asked the Plan to waive the copayment for chemotherapy drugs. You say that you are requesting a 
reconsideration on the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for chemotherapy drugs. The total allowed amount for the 
drugs is $1,204.40. You are being asked to pay is $240.88 ($1204.40 x 20% = $240.88). 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 chemotherapy drugs provided February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatment (97810) and the 
supplies and materials provided by the physician or other qualified health care professional over and above 
those usually included with the office visit or other services (99070) provided on April 25, 2022 and May 13, 
2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 
items/services provided do not meet criteria for payment. 
 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.  
 
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 acupuncture services in this case were not 
provided on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to issue reimbursement for the acupuncture treatment (97810) and the supplies and materials provided by 
the physician or other qualified health care professional over and above those usually included with the office 
visit or other services (99070) provided on April 25, 2022 and May 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health on July 11, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health. You say that you want to appeal the 
amount being charged. 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 $45 
copayment for each in-person specialist visit. Covered services include consultation, diagnosis, and treatment 
by a specialist. 
 
You have been asked to pay a $45 copayment for outpatient mental health. This item/service 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 outpatient mental health on July 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on February 16, 2022 
 
You asked the Plan to pay for the ambulance response. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 February 16, 2022. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on February 16, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an anesthetic and/or steroid injection into 
the sacral spine nerve root (64483) provided on April 12, 2022; April 19, 2022; and June 7, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you have never 
received a bill from this provider for the services at issue before now. You also say that you cannot afford to 
pay the claim. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. You have been asked to pay a $750 copayment for the outpatient hospital services ($250 copayment  3 days 
of service = $750 copayment). This item/service falls within the outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers 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 anesthetic and/or steroid injection into the sacral spine nerve root (64483) 
provided on April 12, 2022; April 19, 2022; and June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 3, 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 May 3, 2022.