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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show at least six weeks of conservative treatment within the past three 
months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags to 
mandate immediate MRI without first trying six weeks of conservative management, including physical 
therapy. There is no evidence of reflex abnormality or weakness. There would be no contraindication to six 
weeks of supervised physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection(s), of an anesthetic agent(s) 
and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, single level (64483) provided 
on December 7, 2021 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery at an ambulatory surgical center and at a hospital outpatient facility. 
 You have been asked to pay a $250 copayment for the outpatient surgery provided. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the injection(s), of an anesthetic agent(s) and/or steroid; transforaminal epidural, 
with imaging guidance, lumbar or sacral, single level (64483) provided on December 7, 2021
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 24, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this ultrasound was medically 
necessary and should be covered. The Plan denied your request. The Plan says the copayment was applied 
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 $45 
copayment for each in-network Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay $45 for the ultrasound. An 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 
the ultrasound provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient evaluation and management (EM) services provided on 
October 9, 2021. 
 
You asked the Plan to pay for the billed EM services. You say that this was billed correctly as code 99232 is 
payable in the inpatient POS. The Plan denied your request. The Plan says that it was determined that 
appropriate place of service was not billed for inpatient visit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The denial rationale indicates that the incorrect place of service (POS) code was 
reported for this date of service. However, the Plan failed to include any copy of the claim, meaning we are not 
able to review what POS code was actually billed, or whether it matches the billed services. We find that the 
denial of payment has not been substantiated. Therefore, we decided that the Plan has to pay for the inpatient 
evaluation and management (EM) services provided on October 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit and chiropractic 
manipulation of one or more of the extra-spinal regions provided from November 29, 2021, through 
December 6, 2021. 
 
You asked the Plan to pay for an office or other outpatient visit and chiropractic manipulation of one or more 
of the extra-spinal regions. The Plan denied your request. The Plan says the services are not eligible for 
coverage under Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit and chiropractic manipulation of one or 
more of the extra-spinal regions provided from November 29, 2021, through December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided November 29, 
2021. 
 
You asked the Plan to pay for the office visit. You say that you have never paid for chiropractic services before 
and you feel this should be covered this time as well. The Plan denied your request. The Plan says this service 
is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code(s): 81291 and 
81479) provided on August 23, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that the claim should be paid. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. The case file contains a GeneSight Order Medical Necessity Documentation form, and the results of the GeneSight 
testing. The documentation is insufficient to support that the GeneSight genetic testing was medically 
reasonable and necessary for the enrollee in this case. Therefore, we decided that the Plan does not have to pay 
for the GeneSight Psychotropic testing (CPT code(s): 81291 and 81479) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 
(CPT code 62320) provided on November 8, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this provider has not submitted the required clinical records to support the medical necessity of 
the service for the date of service requested on appeal and the records provided to the health plan are not dated 
and not signed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Specifically, the documentation submitted does not include a valid 
signature from the persons responsible for the care of the beneficiary. The records provided to the health plan 
are not dated and not signed. There is insufficient documentation of response to prior injection(s) and any 
recent physical exam and pain scale. Therefore, we decided that the Plan does not have to pay for injection(s), 
of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not 
including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, 
cervical or thoracic; without imaging guidance (CPT code 62320) provided on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), bone density 
study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) (CPT code 77080) provided on November 12, 
2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
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. 
 
Code 77080 was billed with only diagnosis code Z13.820 (Encounter for screening for osteoporosis) and it 
requires a valid secondary diagnosis code to identify the reason for the test as per the above guideline. 
Therefore, we decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) (CPT code 77080) provided on November 
12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spine fracture treatment (22326) provided on November 
3, 2021. 
 
You asked the Plan to pay for the spine fracture treatment (22326). You say that the operative note clearly 
dictates the CPT code billed was performed. You say that the documentation should be reviewed, and payment 
released. The Plan denied your request. The Plan says procedure codes 63081, 63082, 22554, 22585, 22846 
and 22854 were approved. The Plan also says procedure code 22326 is not supported by the medical records 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  In this case, the CPT Code Manual definition of code 22326 is open treatment and/or reduction of vertebral 
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical. 
 
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 spine fracture treatment (22326). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not support open treatment or reduction of vertebral fracture or dislocated segment. 
Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the spine fracture treatment (22326) have not been met. Therefore, we decided 
that the Plan does not have to pay for the spine fracture treatment (22326) provided on November 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug injected on November 18, 2021, billed with 80 units 
of code J3300. 
 
You asked the Plan to pay for the injected drug as billed. You say that the records clearly show that 80mg of 
the billed drug were injected. The Plan denied your request. The Plan says the records show that triamcinolone 
diacetate was used which is not described by code J3300. 
 
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 J3300 is Injection, triamcinolone acetonide, preservative 
free, 1 mg. 
 
We find that CPT code J3300 is not supported in the medical record. Specifically, the record shows that 
triamcinolone diacetate was injected which is reported using a different code. Based on this information, we 
decided that Medicare rules for coverage of the injected drug as billed have not been met. Therefore, we decided that the Plan does not have to pay for the drug injected on November 18, 2021, billed with 80 units of 
code J3300.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the services. 
 
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 an epidural injection provided on 
November 15, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound should be included 
in your specialist copayment. 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 $155 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $54.80, which is less than the $155 copayment for the ultrasound. The 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 a retroperitoneal ultrasound provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health treatment. 
 
You asked the Plan to pre-approve continued inpatient mental health treatment. You say that the services are 
medically necessary. The Plan denied your request. The Plan says inpatient care after May 5, 2022 is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 continued inpatient mental health 
treatment. Our reviewer says that continued inpatient services are not medically necessary. Our physician 
reviewer found the patient was compliant and cooperative with treatment. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the inpatient level of care rather than a lower level of care 
beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological services provided on January 3, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological services. You say that that it isn't your responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Ophthalmological services provided on January 3, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
December 17, 2021, through December 19, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the 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 $395 per 
day, for days 1-5 for inpatient hospital care.  
 
You have been asked to pay $790 ($395 copayment x 2 days) for the inpatient hospital care provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
December 17, 2021, through December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hydrogel dressings and wound covers 
provided on February 16, 2022. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that you should not be 
charged the coinsurance since the supplies were not needed. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 20% 
coinsurance for durable medical equipment (DME), including wound care supplies. 
 
 Item Allowed Amount 20% Coinsurance 
Hydrogel Dressing $38.97 $7.79 
Wound Cover $152.10 $30.42 
Total:  $38.21 
 
The file shows that the Plan verified the items were not returned to the vendor. Therefore, you have been asked 
to pay $38.21, which is 20% of the allowed amount for the wound care supplies. The wound care supplies fall 
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 hydrogel dressings and wound covers provided on February 16, 
2022.