Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit, and an inpatient 
hospital stay from October 22, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayments for an emergency room visit, and an inpatient hospital stay. You 
say that you were in the emergency room for multiple days and should not have to pay a copayment for those 
days. The Plan denied your request. The Plan says the proper copayments were applied for the services that 
were billed by the provider. 
 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 $90 
copayment for Emergency care per visit and the Copayment is not waived if admitted to inpatient hospital. 
Your contract with the Plan also clearly says that you must pay a $250 copayment per day for inpatient hospital 
stay for days 1-6 per admission. The total copayment amount for the inpatient hospital stay was $1,000 ($250 
copayment x 4 days). The total copayment amount for the emergency room visit, and an inpatient hospital stay 
was $1,090 ($90 copayment for emergency room + $1,000 copayment for inpatient hospital stay). 
 
You have been asked to pay a $1,090 copayment for an emergency room visit, and an inpatient hospital stay. 
An emergency room visit falls within the Emergency care benefit category. The inpatient hospital stay falls 
within Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an 
emergency room visit, and an inpatient hospital stay from October 22, 2021, to October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the triiodothyronine T3 assay rendered on June 15, 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 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 84480 (triiodothyronine T3 assay) and 84481 
(triiodothyronine T3 free assay). Code 84480 is a column II code with a modifier indicator of 1 when billed 
with column I code 84481. Code 84480 was not billed with an appropriate modifier to allow for separate 
payment. Therefore, we decided that the Plan does not have to pay for the triiodothyronine T3 assay rendered 
on June 15, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an esophagogastroduodenoscopy (EGD), provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for the EGD. You say that the service should be covered. The Plan 
denied your request. The Plan says that the cost share was applied correctly. 
 
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 did not provide a copy of their Evidence of Coverage and we are 
unable to determine if the correct cost share was applied. Therefore, we decided that the Plan has to waive the 
copayment for an esophagogastroduodenoscopy (EGD), provided on October 11, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are considered inclusive to other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 49020: 
 
Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open  
CPT 49203: 
 
Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, 
mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 49020, the operative 
report describes an abscess was encountered and drained during the primary procedure. This service would not 
be reported as a distinct procedural service, but an increased procedural service. However, the documentation 
does not support substantial work was required to treat the abscess, and would not be reported separately. In 
terms of CPT 49203, the operative report describes a biopsy was performed for accessing pathologic 
evaluation, and therefore would not be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed by the enrollee. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 30, 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 testing 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 testing at issue in this appeal was requested solely for screening purposes. The file shows that the laboratory services were billed for diagnosis Z00.00 (encounter for general adult medical examination without 
abnormal findings). Medicare does not cover this testing solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided 
December 21, 2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that please review attached corrected claim 
and supporting medical records and reprocess accordingly for payment. The Plan denied your request. The Plan 
says the records do not support the billed 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 90837 is individual outpatient psychotherapy services, 
60-minute session. 
 
We find that CPT code 90837 is not supported in the medical record. Specifically, you must attempt to consult 
their attending or primary care physician. The submitted claim shows that the referring provider is the same as 
the servicing provider. Based on this information, we decided that Medicare rules for coverage of the 
psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
individual psychotherapy services (90837) provided December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an elbow orthosis provided on September 
30, 2021. 
 
You asked the Plan to waive the coinsurance for an elbow orthosis. You say that you have had problems with 
the equipment and the provider should not receive payment for it. The Plan denied your request. The Plan says 
the proper coinsurance was applied for this service. 
 
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 a prosthetic devices and repair and/or replacement of prosthetic devices. The total amount 
allowed was $71.90 with a coinsurance amount of $14.38 ($71.90 total amount x 20% coinsurance amount). 
 
  You have been asked to pay a $14.38 coinsurance amount for an elbow orthosis. An elbow orthosis falls within 
the Prosthetic devices 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 an elbow orthosis provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the evaluation of cornea to be provided by out-of-
network providers. 
 
You asked the Plan to pre-approve the out-of-network services. You say that it is hard for you to see, and it has 
created this film which makes it hard to drive and is affecting the quality of your life and has been progressing 
within the past two (2) months aggressively. The Plan denied your request. The Plan says there are in-network 
providers that can provide the services you need. 
 
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 the evaluation of cornea to be provided by 
out-of-network providers.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for drug testing performed on 
September 15, 2021. 
 
You asked the Plan to waive the deductible and copayment for the drug testing. You say that you have never 
been billed for these services before. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible and the correct cost sharing amount was charged. 
 
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 there is $300 deductible which applies to certain items and services. 
 
Your contract with the Plan clearly says that you must pay a $10 copayment per day, per provider for lab 
services.  
 The item or service you asked the Plan to waive the deductible and copayment for falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $300 deductible which applies to certain items and 
services. This cost sharing is a contractual obligation that had not been fully met at the time the drug testing 
was received on September 15, 2021.  
 
The file shows that at the time of the drug testing, you had $290.29 remaining to meet your deductible. This 
amount was applied first, then the $10 copayment once the deductible was fulfilled. Therefore, we decided that 
the Plan does not have to waive the deductible and copayment for drug testing performed on September 15, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) with and without 
contrast. 
 
You asked the Plan to pre-approve an MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says the requested MRI does not meet criteria. 
 
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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer says you claim you had recent physical therapy (PT) 
for low back pain without success, however, the submitted records do not show such therapy. Your neuro exam 
is normal so there are no red flags mandating an MRI without first attempting PT. If records can be retrieved 
showing a 6-week trial of PT without success within the past year, you would qualify for the requested MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) with and without contrast.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 14, 2020, to October 18, 2020. 
 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 177 (RESPIRATORY INFECTIONS AND 
INFLAMMATIONS WITH MCC). We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the reviewed documentation indicates that the documentation supported an 
admission for pneumonitis. The documentation was unclear regarding a diagnosis of acute respiratory failure. 
Even though acute respiratory failure is documented, supporting documentation was not found within the 
submitted medical record. There is no documentation of persistent hypoxia. Continuous pulse oximetry and 
DuoNeb treatments are appropriate interventions for pneumonia. There was no evidence of blood gases done to 
support a Pa02 less than 60. DRG 179: RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT 
CC/MCC is the most appropriate DRG in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 14, 2020, to October 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation provided to the 
enrollee on April 26, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the denied services in the setting of chronic right 
knee pain has not been demonstrated in the peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure was considered experimental and investigational. Therefore, the procedure was not 
medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for genicular nerve radiofrequency ablation provided to the enrollee on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on November 9, 2021. 
 
You asked the Plan to pay for this equipment. You say that you researched all 7 of the Medicare durable 
medical equipment suppliers and they were all in Columbus, Ohio. You stated you are a disabled veteran and 
that you do not own a car, nor do you drive. You had a neighbor drive you to a closer provider. You stated that 
while the provider used does not accept Medicare, you would like the Plan to make an exception due to your 
circumstances. The Plan denied your request. The Plan says you did not have prior authorization and the walker 
was purchased from a non-Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items provided by a vendor who is not a Medicare eligible provider. The Plan contract durable medical 
equipment requires prior authorization. You purchased a walker from a non-Medicare eligible provider without 
prior authorization. Therefore, we decided that the Plan does not have to pay for this walker.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of chest without contrast 
(71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested admission to an IRF is 
medically necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does 
not meet criteria. 
 
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 the chest. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the Fleischner Society document 
which serves as the cornerstone for following pulmonary nodules does not advocate surveillance for nodules 
under 6 mm in diameter in low-risk patients, however, this patient has a history of known breast cancer thus 
would be at high risk for metastases. A surveillance CT scan would be reasonable to make certain these 
previously described nodules were not metastatic in nature. 
 
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 the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of chest without contrast (71250).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on October 6, 
2021. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 76705 and 
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 the abdominal ultrasound (76705) provided on October 6, 2021.