Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visit provided on June 30, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
this was an annual wellness visit and not a standard office visit. The Plan denied your request. The Plan says 
that the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees do not pay for annual wellness visits unless there are laboratory tests 
provided in addition to the visit.  
 
The Plan says you must pay a $15 copayment for the office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 for the annual wellness visit. Therefore, we decided that the Plan has to 
waive the copayment for the office visit provided on June 30, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a ct scan provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for the ct scan. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $104.45 copayment for a CT scan, which is less than the standard $110. CT 
scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a ct scan provided on November 11, 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 September 6, 
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 September 6, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET Scan is necessary to see if and how 
much the cancer has progressed. The Plan denied your request. The Plan says the PET Scan is not medically 
necessary as the result does not directly contribute to the plan of care. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer 
found you have declined recommended treatment. Your PSA has risen to 96. Your prior PET/computed 
tomography (CT) using a prostate specific membrane antigen (PSMA) agent showed positive lymph nodes in 
the chest, abdomen and pelvis; no bone lesions. If surveillance imaging is desired a CT of the chest, abdomen 
and pelvis could be obtained to compare the size of the lymph nodes which were noted to be positive on the 
prior PET scan to establish tumor growth. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is physically declining. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness and shortness of breath and was treated for leukemia. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this enrollee 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 IRF admission and services.
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.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (80307) provided on November 9, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that this claim has not been billed in 
accordance with Medicare coding rules. 
 
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. In this case, the Plan has failed to substantiate their denial. The Plan did not 
provide a specific denial reason in their case file. In addition, the justification that is submitted is a Local 
Coverage Article that is not valid for the state the services were performed in. Therefore, we decided that the 
Plan has to pay for the drug testing services (80307) provided on November 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implants (D6010 x6). 
 
You asked the Plan to pre-approve surgical implants. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical implants (D6010 x6).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on August 2, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says that the billed diagnosis is inconsistent with the 
ambulance services billed. 
 
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. Specifically, the Plan has denied payment based on the diagnosis code as billed. 
However, no rules or regulations were included with the Plans denial to substantiate the Plans denial of 
payment for ambulance services specifically based on the diagnosis code. In addition, there is no Local 
Coverage Determination or Local Coverage Article that specified diagnosis codes that should be billed with 
ambulance services. Therefore, we decided that the Plan has to pay for the ambulance services provided on 
August 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on November 16, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that your prescription changed, and you needed new 
glasses. You say that you had not used your eyeglass allowance yet and are confused why the claim was 
denied. The Plan denied your request. The Plan says your $300 eyewear benefit was exhausted with this 
purchase. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 every calendar year for eyewear to correct vision. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of the eyeglasses have not been met. Specifically, the Plan paid $300 toward the eyeglasses 
purchased on November 16, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not 
have to pay more for the eyeglasses purchased on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Blood smear, peripheral, interpretation (85060) provided 
on September 30, 2021. 
 
You asked the Plan to pay for code 85060. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an 
outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for the Blood smear, peripheral, interpretation (85060) provided on 
September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says criteria for inpatient admission is not met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department 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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management services (99441) 
provided August 16, 2021. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was 
directly related to another evaluation and management service. 
 
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 99441 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion.  
 We find that CPT code 99441 is not supported in the medical record. Specifically, the documentation submitted 
indicates that this telephone service was directly related to an evaluation and management service rendered 
within the previous 7 days. There is a more appropriate CPT code to bill for the services rendered. Based on 
this information, we decided that Medicare rules for coverage of the telephone evaluation and management 
service have not been met. Therefore, we decided that the Plan does not have to pay for the telephone 
evaluation and management services (99441) provided August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of skin lesions (17271-79) provided on 
December 7, 2021. 
 
You asked the Plan to pay for code 17271-79. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plans contract, and Medicare rules. Modifier 79 is used to indicate that the 
performance of a procedure or service during the post-operative period was unrelated to the original procedure. The unrelated procedure must be reported during the post-operative period of the original service. The 
procedure performed on November 30, 2021 (11102) has a global surgery period of 0 making modifier 79 
unnecessary. Based on this information, we decided that Medicare rules for coverage of code 17271-79 have 
not been met. Therefore, we decided that the Plan does not have to pay for the destruction of skin lesions 
(17271-79) provided on December 7, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the drug infusion pump implantation. 
 
You asked the Plan to pre-approve the drug infusion pump implantation. The Plan denied your request. The 
Plan says that the records do not show the enrollee has severe intractable pain that cannot be adequately 
managed by non-invasive methods of pain control. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 drug infusion pump implantation. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has chronic low back pain. The enrollee has tried and 
failed ice, heat, medication trials, a home exercise program and has psychological clearance for implantation. 
 
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 drug infusion pump implantation have been met. Therefore, we decided that 
the Plan has to pre-approve the drug infusion pump implantation.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare rules. 
 
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 laboratory 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 the laboratory services provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk genetic testing panel provided on October 11, 
2021. 
 
You asked the Plan to pay for cardiac risk genetic testing panel. You say that this was medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this testing service is not covered. 
 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. 
 
The enrollee is not noted to have a personal history of heart disease. They have risk factors but no 
signs/symptoms of illness. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for cardiac risk genetic testing panel provided on October 11, 2021.