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

 
We decided that the Plan does not have to pay for the Drainage of peritoneal abscess or localized peritonitis 
(49020) provided on November 19, 2021. 
 
You asked the Plan to pay for code 49020. 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. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 49020 
is a column II code to column I code 44143. 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 the Drainage of peritoneal abscess or localized peritonitis 
(49020) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 physician services provided on January 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extracapsular cataract removal surgery 
(66984) provided on April 6, 2021. 
 
You asked the Plan to waive the copayment for the extracapsular cataract removal surgery. 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 $225 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $225 copayment for the extracapsular cataract removal surgery. Extracapsular 
cataract removal 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 an extracapsular cataract removal surgery (66984) provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She requires stand by assistance with her activities of daily living, including bathing, dressing, grooming and toileting. She 
does not require speech therapy. The patient does not require rehabilitation nursing and physician services. She 
is medically stable and does not have complex medical needs such as IV medication or would care. She does 
not require intense skilled occupational and therapies since she is almost at her baseline level of function and is 
stand by assist for mobility and her activities of daily living. The patient does require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. She does not require at least 3 hours a day /5 days a week. She does not require the intensity of 
skilled occupational and therapies in the rehabilitation setting since she is almost at her baseline level of 
function and is stand by assist for mobility and her activities of daily living. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. The patient may be able to participate in physical and occupational 
therapies but she is not expected to significantly benefit since her current level of function is close to her 
baseline. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81206, 81275, 81276, and 81301) 
provided on November 11, 2021. 
 
You asked the Plan to pay for codes 81206, 81275, 81276, and 81301. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory service (81206, 81275, 81276, and 81301) provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder x-ray (73030), neck spine x-ray (72040), and 
transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on March 
13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a shoulder x-ray, neck spine x-ray, and transportation of portable x-ray 
equipment and personnel to home or nursing home provided by an OON provider. You say that the services 
were provided and payment should be rendered. The Plan denied your request. The Plan says prior 
authorization was not received. Therefore, coverage criteria have not been met. 
 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 a shoulder x-ray (73030), neck spine x-ray 
(72040), and transportation of portable x-ray equipment and personnel to home or nursing home (R0070) 
provided on March 13, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established 
patient (92014), fundus photography with interpretation and report (92250), determination of refractive state 
(92015), and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and 
report, unilateral or bilateral; optic nerve (92133) provided on October 13, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the medical eye exam, fundus photography, eye refraction and ophthalmic 
diagnostic imaging. You say that these services should be covered. The Plan denied your request. The Plan 
says these services are not covered because they were provided OON without prior authorization. 
 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 ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; 
comprehensive, established patient (92014), fundus photography with interpretation and report (92250), 
determination of refractive state (92015), and scanning computerized ophthalmic diagnostic imaging, posterior 
segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided on October 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on December 9, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the services were provided, and payment should be 
rendered. The Plan denied your request. The Plan says the documentation does not support those two separate 
services were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the claims processing systems contain edits 
which identify exact duplicate claims and suspect duplicate claims.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have not been met. The medical records show one chest x-ray was performed on the 
date of service. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided 
on December 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic services provided from November 8, 2021, to January 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services were provided out-of-network and were not approved in advance. 
 
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 plan has not included medical records, without medical records we cannot 
determine if the services provided were emergent or not. The Plan did not provide any other rationale or 
evidence to support a denial of payment for this service. Furthermore, the Plan provided no evidence that there 
were in-network providers available to the enrollee at the time the services were obtained. Therefore, we 
decided that the Plan has to pay for the chiropractic services provided from November 8, 2021, to January 11, 
2022, by an out-of-network (OON) provider.  
 
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 the office visit coded 99214 provided on July 8, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not separately payable. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: A detailed 
history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient 
and/or family. 
 
 
 We find that CPT code 99214 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as a minor surgery. This means that payment for this service is included in the 
payment for the procedure. Based on this information, we decided that Medicare rules for coverage of the 
office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit 
coded 99214 provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent antigen detection by immunoassay 
technique services provided on August 5, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the infectious agent antigen detection by immunoassay technique services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services rendered are not a covered benefit. 
 
 
 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 infectious agent antigen detection by 
immunoassay technique services provided on August 5, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on February 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 drug testing provided on February 14, 2022 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transoral gastric outlet reduction. 
 
You asked the Plan to pre-approve transoral gastric outlet reduction. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 transoral gastric outlet reduction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has morbid obesity and has undergone bariatric surgery (roux-
en-Y gastric bypass in 2005) has regained weight. Although promising, the technique is neither standard of 
care nor in widespread use for the enrollee's indication. Its medical necessity and appropriateness, nor optimal 
safety, is not demonstrated for the enrollee based on the records received and reviewed, particularly in light of 
the enrollee's multiple documented co-morbidities. Therefore, the enrollee does not meet criteria for the 
requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transoral gastric outlet reduction have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transoral gastric outlet reduction.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of abdomen (74170) 
 
You asked the Plan to pre-approve a CT scan of abdomen (74170). You say that the previous CT scan showed 
an incidental finding of a left adrenal nodule, and a follow up CT scan was recommended by the radiologist. 
You say that you ordered the scan and payment for testing should be approved. The Plan denied your request. 
The Plan says that a repeat CT scan is not reasonable or medically necessary until 12 months later. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of abdomen (74170). Our 
reviewer says that the request for a dedicated CT using adrenal protocol is reasonable and should be approved. 
Our physician reviewer found there is a dedicated adrenal mass protocol that is followed by radiologists to 
determine if an adrenal mass is likely an adenoma, carcinoma, pheochromocytoma or metastatic mass. This 
protocol requires unenhanced imaging followed by post contrast imaging including delayed imaging. While 
most adrenal masses or nodules turn out to be adenomas there are instances when the nodule is neoplastic in 
nature and early detection is necessary to provide a cure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of abdomen (74170) have been met. Therefore, we decided that the 
Plan has to pre-approve a CT scan of abdomen (74170)  
 
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: Favorable

 
We decided that the Plan has to pay for reimbursement of a Covid-19 test kit purchased on March 26, 2021. 
 
You asked the Plan to pay for reimbursement of the Covid-19 test kit. You say that you submitted the 
appropriate documentation showing proof of payment and you should be reimbursed for the test kit. The Plan 
denied your request. The Plan says that proof of payment was not submitted. Therefore, coverage criteria for 
reimbursement have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of reimbursement of a Covid-19 test kit have been met. A receipt showing proof of payment for the 
Covid-19 test kit purchased March 26, 2021, was submitted. Therefore, we decided that the Plan has to pay for 
reimbursement of a Covid-19 test kit purchased on March 26, 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.