Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of an extremity Doppler study provided on December 
20, 2021. 
 
You asked the Plan to pay for the Doppler interpretation. You say that this was medically necessary to evaluate 
for clots. The Plan denied your request. The Plan says that this does not meet Medicare criteria. 
 
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 did not provide an appeal determination in this case. We are not able to 
confirm the validity of the denial of payment based on the documentation submitted. Therefore, we decided 
that the Plan has to pay for the interpretation of an extremity Doppler study provided on December 20, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 8, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were moved to a private room 
and thought you had been admitted. 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 $100 
copayment for each emergency room visit.  
 
The file does not show evidence of an order for inpatient care by the provider. Therefore, you have been asked 
to pay a $100 copayment for the ER visit. The ER visit falls within the Emergency Care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on September 8, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on February 
7, 2022. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you asked the physician why 
he sent you to this facility. You said that the physician said that it would not be a hospital copayment and it is 
the only place he does procedures. The Plan denied your request. The Plan says you have been charged the 
correct copayment 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 $325 
copayment for same-day outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the cystourethroscopy. The cystourethroscopy falls within 
the Outpatient hospital 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 a 
cystourethroscopy provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 15, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says there was not a valid authorization found on file for the service in 
question. 
 
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 home health services provided on February 15, 
2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this provider is your primary care doctor, and 
you should be paying this bill for blood work that was ordered by your new primary care doctor. 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 said 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 laboratory services provided on December 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of collateral ligament (26540) provided on 
November 12, 2021. 
 
You asked the Plan to pay for the repair of collateral ligament (26540). You say that there are no bundling edits 
with CPT code 26540 and CPT code 26531. You say that the operative report is enclosed for review and proper 
reimbursement should be issued. The Plan denied your request. The Plan says CPT code 26540 is considered 
inclusive to CPT code 26531. 
 
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 26540 is repair of collateral ligament, 
metacarpophalangeal or interphalangeal joint. 
  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 repair of collateral ligament (26540). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the operative report describes the collateral ligament repair was performed with a more comprehensive 
procedure. In this case, CPT 26540 would be inclusive to the more comprehensive procedure. 
 
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 repair of collateral ligament (26540) have not been met. Therefore, we 
decided that the Plan does not have to pay for the repair of collateral ligament (26540) provided on November 
12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and debridement services (11720, 11305, 
99213) provided on November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and debridement services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 debridement services (11720, 
11305, 99213) provided on November 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for remote device evaluation provided to the enrollee on February 16, 
2022. 
 
You asked the Plan to pay for the services. You say that you disagree with your cost share, as you did not 
receive any treatment for this date of service, or for the month of February. The Plan denied your request. The 
Plan says that Current Procedural Terminology (CPT) 93295 and 93296 are reported no more than once every 
90 days. 
 
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 substantiated their denial. The plan's cited coverage article is 
not valid for your state. Therefore, you are not subject to the 90 day coverage frequency used by the plan in 
your denial. Additionally, the plan has not submitted any medical records for review from the date of service 
for February 16, 2022, or any prior remote evaluations. The plan's denial reasons cannot be verified. Therefore, 
we decided that the Plan has to pay for remote device evaluation provided to the enrollee on February 16, 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 pay for the at home COVID-19 test kits purchased December 23, 
2021. 
 
You asked the Plan to pay for the at home test kits. You say that you received a notice indicated you can submit 
the tests for reimbursement. The Plan denied your request. The Plan says this item was not a covered item at 
the time of service. 
 
The Plan must follow Medicare rules. The Plan will provide coverage for over-the-counter, FDA approved or 
Emergency Use Authorized (EUA) antigen & molecular, At-Home COVID-19 tests. Coverage applies to 
eligible tests that are purchased on or after February 1, 2022 through the end of the federal public health 
emergency (PHE) or December 31, 2022, whichever is earlier. The rules say that Medicare does not pay for 
OTC items and the at home test kit is an OTC item. Therefore, we decided that the Plan does not have to pay 
for the at home COVID-19 test kits purchased December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computerized Tomography (CT scan) on 
February 09, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that the copayment is too high and 
questioned why you had a cost share. The Plan denied your request. The Plan says the cost-sharing you are 
being charged 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 a $180 
of the cost for each Medicare-covered special imaging procedure and special diagnostic test.  
 
You have been asked to pay a $180 copayment for CT scan. CT scans fall 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 
Computerized Tomography (CT scan) on February 09, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography, of the upper 
extremity; without contrast material (73200) provided on January 10, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $170 
copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physicians office or at a free-standing facility.  
 
You have been asked to pay $160.78 for the in-network Medicare-covered radiological diagnostic service 
provided. This is the Plans allowed amount for this service, which is less than the applicable copayment.  
 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 computed tomography, of the upper extremity; without 
contrast material (73200) provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophageal motility study (91010) 
provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for the esophageal motility study. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $350 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $350 copayment for the esophageal motility study. the esophageal motility study 
falls within the Outpatient hospital 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 an esophageal motility study (91010) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 provided on January 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (10008) provided November 10, 2021. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was an add-on code billed without a required primary 
procedure. 
 
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 the surgical services is an add-on code and has not been billed with an appropriate primary procedure code. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for surgical services (10008) provided November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient laboratory services (86833, 86832) provided 
on February 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that please review for payment due to medical 
necessity. Attached is medical records for review. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 outpatient laboratory services (86833, 86832) 
provided on February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drainage of peritoneal abscess (49020) provided on 
December 13, 2021. 
 
You asked the Plan to pay for the drainage of peritoneal abscess (49020). You say that the attached supporting 
documentation should be reviewed, and the claim reprocessed accordingly. The Plan denied your request. The 
Plan says procedure code 49020-XS is not supported by the medical records submitted. 
 
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 49020 is drainage of peritoneal abscess or localized 
peritonitis, exclusive of appendiceal abscess, open. 
 
  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 drainage of peritoneal abscess (49020). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the operative report describes a hematoma and does not include documentation of peritoneal abscess or 
localized peritonitis. Therefore, the abscess drainage cannot be verified. 
 
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 drainage of peritoneal abscess (49020) have not been met. Therefore, we 
decided that the Plan does not have to pay for the drainage of peritoneal abscess (49020) provided on 
December 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital observation care 
provided on January 25, 2022, and ambulance transportation provided on January 26, 2022. 
 
You asked the Plan to waive the copayments for the observation care and ambulance transportation. You say 
that the copayment amounts are too high. 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 $310 
copayment for an observation stay. Your contract with the Plan also clearly says that you must pay a $260 copayment for each one-way ambulance 
trip. 
 
You have been asked to pay a $310 copayment for the observation care. The observation care falls within the 
Outpatient Hospital Observation benefit category. You have also been asked to pay $242.02 for the ambulance 
transportation, which is less than the $260 copayment. The ambulance transportation falls within the 
Ambulance Services benefit category. The total for the services is $552.02. 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 copayments for outpatient hospital observation care provided on January 25, 2022, and ambulance 
transportation provided on January 26, 2022.