Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cardiology specialist office visits provided 
on November 1, 2021, and December 21, 2021, the electrocardiogram (ECG) provided on November 1, 2021, 
or a cardiovascular stress test provided on December 17, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits, ECG, and stress test. You say that 
you were in the hospital with COVID-19, and it was recommended to follow up with a cardiologist. You also say that these outpatient copayments should be waived since they are related to COVID-19. 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 $10 
copayment for diagnostic testing, including ECGs. The Plan contract also says that enrollees must pay a $150 
copayment for advanced imaging services, including stress tests. The Plan contract also says that enrollees 
must pay a $35 copayment for a specialist office visit. 
 
The record shows the primary diagnosis for these services was not COVID-19. You have been asked to pay a 
$10 copayment for an ECG on November 1, 2021. An ECG falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have also been asked to pay the allowed amount of 
$69, which is less than the $150 copayment for a stress test on December 17, 2021. A stress test falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked 
to pay a $35 copayment for each specialist office visit on November 1, 2021, and December 21, 2021. A 
specialist office visit falls within Physician/Practitioner Services, Including Doctors 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 copayments for cardiology specialist office visits provided on 
November 1, 2021, and December 21, 2021, the electrocardiogram (ECG) provided on November 1, 2021, or a 
cardiovascular stress test provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4550, A4556, A4557, A4649, 
S1015 and S8301 provided on October 27, 2021. 
 
You asked the Plan to pay for procedure codes 99072, A4550, A4556, A4557, A4649, S1015 and S8301. You 
say that the anesthesia services were requested by the doctor who is in-network. You say that the patient didnt 
have a choice of anesthesiologists and the claim should be processed appropriately as an in-network claim. The 
Plan denied your request. The Plan says procedure codes 99072, A4550, A4556, A4557 and A4649 are 
considered bundled and not separately payable. The Plan also says procedure codes S1015 and S8301 are 
invalid for Medicare billing purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  We find that CPT codes 99072, A4550, A4556, A4557, A4649, S1015 and S8301 are not supported in the 
medical record. Specifically, procedure codes 99072, A4550, A4556, A4557 and A4649 have a status indicator 
of B or P. This means that these services are considered bundled and not separately payable. In addition, CPT 
codes S1015 and S8301 have a status indicator of I. This means that these CPT codes are invalid for Medicare 
billing purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes 
99072, A4550, A4556, A4557, A4649, S1015 and S8301 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99072, A4550, A4556, A4557, A4649, S1015 and S8301 
provided on October 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital facility charges provided on 
October 4, 2021. 
 
You asked the Plan to waive the copayment for hospital facility charges. You say that you should have been 
made aware of the Cologuard test false positivity rates before taking the test and then having a colonoscopy. 
You also say that you would have chosen getting just the colonoscopy alone as it is covered.  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 $150 
copayment for in-network outpatient surgery at an outpatient hospital, including hospital or other facility 
charges. The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$150 copayment for hospital facility charges. Hospital facility charges falls within the Outpatient Surgery and 
Other Medical 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 hospital facility charges provided on October 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1971, L3170) provided October 21, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the billed item is not supported in the records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the physician discussed the need for the items with the enrollee.. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L1971, L3170) provided October 21, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service September 
20, 2021. 
 
You asked the Plan to pay for procedure code 99291. You say that this was a separately identifiable evaluation 
and management service and should be paid. The Plan denied your request. The Plan says separate payment 
cannot be made for code 99291 when billed on the same day as code 90945 and no modifier is appended. 
 
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 99291 
is a column II code to column I code 90945. 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 99291 billed for date of service September 20, 
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 December 
27, 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 27, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that you feel that this treatment should be 
approved to help your condition. The Plan denied your request. The Plan says there is insufficient evidence of 
medical necessity at this time. 
 
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 the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Superion Spacer is experimental. More research is needed to show safety and 
efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142, 99100) provided April 5, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 We find that CPT codes 00142, & 99100 are not supported in the medical record. Specifically, CPT 99100 has 
a status of "B" per the National Physician Fee Schedule. Payment is bundled. Records provided do not support 
CPT 00142 on the date of service in question. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (00142, 99100) provided April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinic visits (G0402, G0463, 90732, G0009) provided on 
September 20, 2021. 
 
You asked the Plan to pay for clinic visits. You say that these services are supported in the records. The Plan 
denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that hospitals subject to Outpatient Prospective 
Payment System (OPPS) report Condition Code G0 on Form Locators (FLs) 24-30 (or the corresponding 
electronic location) when multiple medical visits occurred on the same day in the same revenue center but the 
visits were distinct and constituted independent visits. 
 
We looked at the file and Medicare rules. Multiple medical visits (G0402, G0463) were billed on the claim at 
issue, but condition code G0 was not reported. Based on this information, we decided that Medicare rules for 
coverage of clinic visits have not been met. Therefore, we decided that the Plan does not have to pay for clinic 
visits (G0402, G0463, 90732, G0009) provided on September 20, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on May 14, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the claim has been processed 
and underpaid. You say that the claim should be sent back for review and reprocessing. The Plan denied your 
request. The Plan says bundled services are not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the special anesthesia service (99100) have 
not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service 
(99100) provided on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (34101) provided August 30, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 34101 is embolectomy or thrombectomy, with or without 
catheter, in the axillary, brachial, innominate, or subclavian artery, by arm incision. 
 
We find that CPT code 34101 is not supported in the medical record. Specifically, the operative report does not 
show a separate incision made. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (34101) provided August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95869, 95870) provided February 
18, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95869, & 95870 are not supported in the medical record. Specifically, 95870 and 
95869 are considered inclusive to procedure code 95939. Based on this information, we decided that Medicare 
rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does 
not have to pay for neuromonitoring services (95869, 95870) provided February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
17, 2021, to July 23, 2021. 
 
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 DRG was downgraded in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 380 (COMPLICATED PEPTIC ULCER 
WITH MCC). We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer 
says that the services at issue in this case were not supported by the medical records. Our physician reviewer 
found the review has determined that DRG 380 is not appropriate; DRG 381 is more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 17, 2021, to July 23, 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 November 6, 2021, to December 5, 2021. 
 
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 100 days of services have been received already. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 17, 2021 to 
January 12, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 6, 
2021, to December 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77062) provided October 26, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "I" and is invalid for Medicare payment. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for radiology services (77062) provided October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that you have trouble getting out of bed and requires the 
features on a hospital bed. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you have a condition that requires frequent positioning of the bed and mattress to alleviate 
pain, promote good body alignment, prevent contractures, or avoid respiratory infections in a way that an 
ordinary bed is not able to. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
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 
29, 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 29, 
2021.