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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 18, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 8, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this was done in office and not 
in the hospital. The Plan denied your request. The Plan says the copayment applied 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 $300 
copayment for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay $300 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided 
on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric hospital bed and a Roku air mattress 
(E0193). 
 
You asked the Plan to pre-approve an electric hospital bed and a Roku air mattress. You say that you have been 
trying to get a Roku mattress since February. You also say you are too tall for your standard bed. You need the 
electric bed so you can have a better life because the hospital bed is uncomfortable. The Plan denied your 
request. The Plan says you were previously provided with a standard hospital bed and an air pressure pad. The 
Plan does not provide coverage for electric hospital beds because the height adjustment feature is a 
convenience feature. The Roku air mattress is not a brand covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The records also show that a Roku mattress is not a brand the Plan covers. Therefore, 
we decided that the Plan does not have to pre-approve an electric hospital bed and a Roku air mattress (E0193).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services on January 31, 2022. 
 
You asked the Plan to waive the copayments for chiropractic services. You say that You were given incorrect 
information about your pending claim for chiropractic visits. 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 $15 
copayment for each Medicare-covered chiropractic visit. Covered services include we cover manual 
manipulation of the spine to correct subluxation. Prior authorization rules may apply for network services. 
Your network provider is responsible for requesting prior authorization. Our plan recommends pre-
authorization of the service when provided by an out-of-network provider. The provider billed in the amount of 
$145 and the allowed amount is $145. Also billed in the amount of $117 and the allowed amount is $117. Also 
billed in the amount of $248 and the allowed amount is $248. $145 + $117 + $248 + $15 = $525.00. Therefore, 
results in the total cost sharing amount of $525.  
 
 You have been asked to pay a $525 copayment for chiropractic services. Chiropractic services fall within the 
Chiropractic 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 copayments for 
chiropractic services on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary testing provided to the enrollee on July 16, 2021. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says there are insufficient medical records provided to show how the results of this testing 
will be used to treat active disease in the enrollee. This test is not covered as a screening. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the hereditary testing were met. 
Therefore, we decided that the Plan does not have to pay for hereditary testing provided to the enrollee on July 
16, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 1, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the -54 modifier is billed for surgical are only when 
physicians agree on the transfer of care during a global surgical period. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99284 was billed with the -54 
modifier. This modifier is not appropriate for the services at issue. Therefore, we decided that the Plan does not 
have to pay for the emergency room (ER) services rendered on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (three- or four-wheel 
nonhighway) specify brand name and model number (E1230). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the enrollee needs this power scooter 
to help with his doctors appointments and shopping. You also say no home evaluation has been done to see if 
this scooter can fit in the enrollee's home. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval of a power scooter. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (three- or four-wheel nonhighway) specify brand name and 
model number (E1230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on January 19, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the evidence supporting the 
use of Cxbladder Detect as a medically necessary diagnostic service is well established. 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 Cxbladder detect test (0012M) provided on 
January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the prostate specific antigen (PSA) screening 
provided on April 11, 2022. 
 
You asked the Plan to waive the copayment for the PSA screening. You say that this should have been covered 
in full. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees pay no copayment for an annual PSA screening deductible does not 
apply for Prostate Cancer Screening Exams.  
 
The Plan says you must pay $18.39 toward the deductible for the PSA test. The records do not support that you 
have already received a PSA test in the Plan year. This means that the Plan has not supported this service was 
diagnostic in nature for $18.39 to apply toward the deductible. Based on the Plan contract, however, you cannot 
be asked to pay more than $0, there is no copayment for an annual PSA screening deductible does not apply for 
the PSA screening. Therefore, we decided that the Plan has to waive the copayment for the prostate specific 
antigen (PSA) screening provided on April 11, 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 pre-approve a power seat elevator (E2300) and a color shroud 
(K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevator (E2300) and a color shroud (K0108) 
for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to appeal the denial of 
the authorization. The Plan denied your request. The Plan says the member is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower level of care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on March 28, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that this should be covered. The Plan denied 
your request. The Plan says the coinsurance applied 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 10% of 
the total cost for each Medicare-covered durable medical equipment item.  
 
You have been asked to pay $44.40 which is 10% of the allowed amount for DME. The allowed amount is 
$444 (10% x $444= $44.40). DME falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for DME provided on March 28, 
2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 at-home test kit you purchased on January 16, 
2022. 
 
You asked the Plan to pay for the test kit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has started a new initiative on April 4, 
2022, that will cover up to eight over-the-counter COVID-19 tests each calendar month, at no cost to you.  
 
We looked at the file and Medicare rules. As you purchased the at-home test kit prior to April 4, 2022, this is 
not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the test kit 
have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 at-home test kit 
you purchased on January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
15, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says the copayment applied 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 $45 
copayment per visit to a specialist.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
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 copayment for specialist office visit provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic services to be provided by an OON provider. 
 
You asked the Plan to pre-approve prosthetic services. You say that you are appealing the denial of medical 
coverage based on it is a medical necessity. The Plan denied your request. The Plan says you must receive your 
care from a network provider. The service was already approved at the in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
prosthetic services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 20, 
2021. 
  You asked the Plan to pay for procedure code 70544. You say that the attached medical records support the 
services, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service October 20, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this 
transportation to get to therapy treatment. The Plan denied your request. The Plan says that this request exceeds 
the benefit limit. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 11, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you did not have the procedure done 
and should not be responsible for the payment. 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 $100 
copayment per day for a Medicare-covered ultrasound. Covered services include, but are not limited to 
diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan. 
 
You have been asked to pay a $100 copayment for ultrasound. Ultrasound 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 ultrasound on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal 
disease (ESRD) provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contract with the dialysis facility which indicates that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal 
disease (ESRD) provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, & 84295 billed for date of 
service December 14, 2021. 
 You asked the Plan to pay for procedure codes 82435, 84132, & 84295. You say that the services were 
medically necessary. The Plan denied your request. The Plan says payment for codes 82435, 84132, & 84295 is 
bundled into payment for code 80051. 
 
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 codes 
82435, 84132, & 84295 are column II codes to column I code 80051. 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 codes 82435, 84132, & 84295 
billed for date of service December 14, 2021.