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

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous fixation device. 
 
You asked the Plan to pre-approve an Aurora Spine ZIP Interspinous fixation device. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 an Aurora Spine ZIP Interspinous 
fixation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the aurora spine zip device 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 an Aurora Spine ZIP Interspinous fixation device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous fixation device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on January 
31, 2022, to February 01, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you were never told about 
the copayment beforehand so it should be covered. 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 $70 
copayment for specialist visits. 
 
You have been asked to pay a $70 copayment for specialist office visit. This item/service falls within the 
specialist 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 specialist office visit 
provided on January 31, 2022, to February 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 22, 2022. 
 
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 there are no modifiers allowed with this code edit. 
 
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 11102 
is a column II code to column I code 11104 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 provided to the enrollee on March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test provided on April 22, 2022. 
 
You asked the Plan to waive the copayment for a stress test. You say that your provider ordered this test, and 
should not have a copay. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for a stress test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the 
copayment for a stress test provided on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone biopsy/excision of a left jaw lesion/cystic structure 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor does not comment about concerns for infection, cancer, or an aggressive 
condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while the provided records document two physician's opinions that there is a need for evaluation of 
the jaw lesion to rule out an infection so that other procedures can be pursued, there is no medical record 
provided to this reviewer from the oral surgeon as to what course of action is indicated in this regard. No 
history, physical examination or results of imaging of the lesion have been provided to this reviewer to meet 
Medicare criteria for the requested biopsy or excision. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone biopsy/excision of a left jaw lesion/cystic structure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission for left total shoulder replacement 
provided to the enrollee on September 1, 2021 and September 2, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says this service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the procedure is not on the inpatient only list, and currently approved as am 
ambulatory procedure. There was no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. The review has determined that the record did not show that at the time 
of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for left total shoulder replacement provided to the enrollee 
on September 1, 2021 and September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43235 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 43235. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 43235 is bundled into payment for code 91035. 
 
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 43235 is a column II code to column I code 91035. 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 43235 billed for date of service May 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on May 11, 
2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you should not have to pay 
for a test that was ordered by your doctor. 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 $98.58 
copayment for diagnostic radiology services (ultrasound). 
 
You have been asked to pay a $98.58 copayment for the breast ultrasound. This item/service falls within the 
diagnostic radiology services (ultrasound) 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. Per the EOC, there is a $100 copayment for ultrasounds. Since the allowed 
amount for this ultrasound is $98.58, you are only responsible for the lesser amount. Therefore, we decided that 
the Plan does not have to waive the copayment for the breast ultrasound provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says that these services were not 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 an office visit provided on May 11, 2022, by an 
out-of-network (OON) provider.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 clinical documentation shows that you have functional impairments and evaluating 
therapists do recommend intense therapy however, you do not have an IRF compliant diagnosis and no active comorbidities that would require continued inpatient hospitalization during rehabilitation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
December 5, 2018. 
 
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 providers have 365 days from the date of service to submit an appeal. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until May 13, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital services provided to the enrollee on December 5, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominoplasty and panniculectomy. 
 
You asked the Plan to pre-approve abdominoplasty and panniculectomy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 abdominoplasty and panniculectomy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the record indicates that you have a ventral hernia and 
rectus diastasis that is planned to be repaired. The record does not indicate that the requested procedure is 
planned. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of abdominoplasty and panniculectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve abdominoplasty and panniculectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided 
from April 19, 2022, to April 26, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you feel you 
should not be responsible to pay for the extended 6-day stay that occurred due to being prescribed a medication 
that you were allergic to. You say that you were told no one contacted the Plan to obtain approval of the stay. 
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 $295 
copayment per day for days 1 to 6 and $0 copayment for additional days for Medicare-covered hospital care 
each time you are admitted.  
 
 
  You have been asked to pay a copayment of $1,770 for days 1 to 6 of an acute inpatient hospital stay ($295 per 
day x 6 days = $1,770). This item/service falls within the Inpatient Hospital 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 acute inpatient hospital stay provided from April 19, 2022, to 
April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test on June 27, 2022, 
to June 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. 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 $100 
copayment for outpatient diagnostic test at outpatient hospital. Covered services include but are not limited to 
other outpatient diagnostic tests. There were 2 dates of service. 2 x $100 = $200. Therefore, results in the total 
cost sharing amount of $200.  
 
You have been asked to pay a $100 copayment for each outpatient diagnostic test. This item/service falls 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient diagnostic test on June 27, 2022, to June 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the psychotherapy services provided on 
March 04, 2022, to July 08, 2022. 
 
You asked the Plan to reduce the copayment for the psychotherapy services. You say that your mental health 
visits cost more than your specialist visits. 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 $440 
copayment for outpatient mental health care. 
 
You have been asked to pay a $440 copayment for the psychotherapy services. This item/service falls within 
the outpatient mental health 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. The file shows 11 psychotherapy visits from March 4, 2022, to July 8, 2022. Per 
the EOC, there is a $40 copayment per visit, for a total of $440. Therefore, we decided that the Plan does not 
have to reduce the copayment for the psychotherapy services provided on March 04, 2022, to July 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a prostate exam provided on June 7, 2022. 
 
You asked the Plan to waive the copayment for a prostate exam. You say that you feel the hospital is "double 
billing" you for this exam. 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 $325 
copayment for outpatient hospital services.  
 
You have been asked to pay $138.19, which is less than the original copayment of $325 for a prostate exam. 
This item/service 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 prostate exam provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure codes 95886, 95908, 95937) 
provided to the enrollee on February 7, 2022. 
 
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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
 CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that none of services/codes under 
review are supported by the records. For CPT 95908, there was not a nerve conduction study done. Rather, 
triggered electromyography (EMG) testing was performed, and this is considered part of the EMG service.  
There was no evidence that a nerve conduction study (NCS) was performed. As such this CPT code would not 
have been appropriate. As NCS was not done as described above, submission of CPT code 95886 would not 
reflect proper coding. Therefore, this code is also not supported by the records. Finally, CPT 95937 is also not 
supported by the records. Only train of four monitoring was done. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurology services (procedure codes 95886, 95908, 95937) provided to the enrollee on 
February 7, 2022.