Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for psychotherapy visits provided 
on December 3, 2020, and December 21, 2020. 
 
You asked the Plan to reimburse you for psychotherapy visits. You say that you received a reimbursement 
check for dates of service before December 2020 and after December 2020. The Plan denied your request. The 
Plan says that the dates of service, December 3, 2020, and December 21, 2020, were included in the 
reimbursement check dated December 14, 2021. The Plan also says you have been reimbursed the correct 
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 $35 
copayment for each outpatient mental health visit.  
 The record shows you received a check from the Plan for $340.64, dated December 14, 2021. The Explanation 
of Benefits shows that the check amount covered the reimbursement for dates of service November 2, 2020, 
November 3, 2020, December 3, 2020, and December 21, 2020. The Plan paid $85 as their share for each of 
those dates. You are responsible for the remaining $35 for each of those dates as your copayment. The check 
from the Plan also included $0.64 for interest. You have been asked to pay a $35 copayment for psychotherapy 
visits. Psychotherapy visits fall within the Outpatient Mental Health Care benefit category. This means that you 
have been reimbursed 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 provide additional reimbursement for psychotherapy visits provided on December 3, 2020, 
and December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 29, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was a "Welcome to Medicare" 
visit, which has no charge. The Plan denied your request. The Plan says some of the services provided were not 
routine, thus making the visit an office visit with a copayment amount of $20. 
 
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 a $20 copayment for each primary care physician's office visit.  
 
The enrollee has been asked to pay a $20 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category.   
 
 
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 waive the copayment for an office visit provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99218) provided on May 27, 2021. 
  You asked the Plan to pay for initial observation care (99218). You say that the procedures were separately 
identifiable and medically necessary. You say that the procedures performed warrant separate payment for each 
CPT code. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair. 
 
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 99218 
is a column II code to column I code 99223. This claim cannot be billed with a 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 initial observation care (99218) provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that transfer to an IRF is the best chance for you to get 
back on your feet and interrupting your inpatient care now will prevent you from full rehabilitation. The Plan 
denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the 
services you need in an alternate setting, such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service November 
19, 2021. 
 You asked the Plan to pay for procedure code 74018. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for 
code 74250. 
 
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 74018 
is a column II code to column I code [insert column I code]. 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 74018 billed for date of service 
November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Colorectal cancer screening (G0328) provided December 9, 
2021. 
 
You asked the Plan to pay for Colorectal cancer screening. You say that you have had this procedure multiple 
times and has always been processed. The provider had resubmitted the claim and it is still being denied. The 
Plan denied your request. The Plan says the benefit has been exhausted. 
 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. 
 
This service is covered once every 12 months. The records show this service was completed July 17, 2021 and 
the Plan had covered this service. Therefore, we decided that the Plan does not have to pay for Colorectal 
cancer screening (G0328) provided December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive genomic profile (CGP) screening testing 
providing May 28, 2021. 
 
You asked the Plan to pay for the screening testing. You say that the provider regarded the test as a medically 
necessary and valuable tool when determining treatment for the enrollee. The Plan denied your request. The 
Plan says the billed code cannot be verified. 
 
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 find that CPT codes 81210, 81275, 81276, 81292, 81295, 81298, 81311, 81317, 81301, 81309 
and 81191 is not supported in the medical record. Specifically, to report a Comprehensive Genomic Profile (CGP) screening service providers should use 1-unit only of CPT code 81479 for the entire bundled multi-test 
panel, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test. 
Based on this information, we decided that Medicare rules for coverage of the screening testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the comprehensive genomic profile (CGP) 
screening testing providing May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on November 
22, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that the procedure code is billed correctly. 
The Plan denied your request. The Plan says rules for payment have 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. 
 
In this case, the records suggest that this service was rendered in an outpatient facility. CPT code 99153 has a 
professional/technical component indicator of 3. This means that this code has a technical component only. Payment for the technical component of the code is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for 
coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have 
to pay for moderate sedation services (99153) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) presumptive drug testing 
(80307) provided on November 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you conducted the laboratory testing 
ordered by the referring provider, who deemed the services to be medically necessary. 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 definitive drug testing (G0483) presumptive drug 
testing (80307) provided on November 12, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service is covered by Medicare. 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 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 August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
26, 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 November 26, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires the care of a SNF due 
to his condition. The Plan denied your request. The Plan says daily skilled services are not required. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male with renal cell 
and metastatic esophageal cancer. From a nursing perspective, the beneficiary received oral medications. The 
beneficiary had stable vital signs, and his lungs were clear. Regarding rehabilitation services, the beneficiary 
received physical and occupational therapy. The beneficiary was at a contact guard to minimal assist level with 
functional mobility including gait to 40 feet. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy services are not required on a daily basis. This beneficiary does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (82310, 82728, 83540, 83550, 83970, 
84100) provided on July 14, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory testing (82310, 82728, 83540, 83550, 83970, 84100) provided on July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93306) provided on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. 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 $160 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $160 copayment for an echocardiography. Echocardiographys 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 an echocardiography (93306) provided on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has not 
responded to skilled therapy services. The documentation does not support that it is medically reasonable and 
necessary at this time to provide skilled services on a daily basis. 
 
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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a botulinum toxin injection and a 
neurology specialist office visit provided on November 10, 2021. 
 
You asked the Plan to waive the cost sharing for an injection and a specialist office visit. You say that you were 
not informed of the charges for the injections. You also say you cannot afford to the $238.79. 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 20% 
coinsurance for Part B drugs that are administered by a provider.  The Plan contract also says that enrollees must pay a $50 copayment for a specialist office visit.   
 
You have been asked to pay $188.79, which is 20% of the allowed amount for an injection ($943.95 allowed 
amount x 20% coinsurance = $188.79). An injection falls within the Medicare Part B Prescription Drugs 
benefit category.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. You have been asked to 
pay a total of $238.79 ($188.79 coinsurance + $50 copayment = $238.79). 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 cost sharing for a botulinum toxin injection and a neurology specialist office visit provided on 
November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), the x-ray exam of the lumbar spine 
(72100), and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on July 16, 
2021. 
 
You asked the Plan to pay for these 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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213), the x-ray exam of the lumbar spine (72100), and the 
routine venipuncture (36415) rendered by the out-of-network (OON) provider on July 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76536) provided on October 
28, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. 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 $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $102.70 copayment for an ultrasound, which is less than the standard $110. 
Ultrasounds 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 an ultrasound (76536) provided on October 28, 
2021.