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

 
We decided that the Plan does not have to pay for the selective catheter placement services coded 36247, 
36246, and 36248 provided on December 3, 2021. 
 
You asked the Plan to pay for the selective catheter placement services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 36247 
is a column II code to column I code 37228. In this case, we have confirmed that code 36246 is a column II 
code to column I code 37228. In this case, we have confirmed that code 36248 is a column II code to column I 
code 37228. 
 
These claims have 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 selective catheter placement services coded 36247, 36246, and 36248 provided on December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for epidural steroid injection with imaging 
guidance provided from May 5, 2021, to November 15, 2021. 
 
You asked the Plan to waive the copayment for epidural steroid injection with imaging guidance. You say that 
you received no notification that your plan changed its benefits and started charging the $250 copayment. The 
Plan denied your request. The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital setting.  
 
  You have been asked to pay a total of $750 for epidural steroid injection with imaging guidance ($250/visit x 3 
visits = $750). Epidural steroid injection with imaging guidance 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 epidural steroid injection with imaging guidance provided from May 
5, 2021, to November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Infed and Venofer. The documentation does not support that Infed and 
Venofer would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete 
series of x-rays (D0210) provided by an out-of-network provider on January 22, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and the complete series of x-rays 
(D0210). You say that you received a bill after you were seen by the dentist and now have a $399 bill that you 
cannot afford to pay. The Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive oral evaluation 
(D0150) and the complete series of x-rays (D0210) are covered services, however, you may be billed by the 
out-of-network provider for any amount greater than the payment made by the Plan under this benefit. The 
record shows the provider is out-of-network. See chart below. 
 
Date of Service Service Amount Billed by 
Provider 
Allowed Amount Different Between 
Amount Billed and 
Allowed Amount 
January 22, 2022 D0150 $80.00 $35.00 $45.00 
January 22, 2022 D0210 $135.00 $64.00 $71.00 
Total    $116.00 
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the complete series of x-rays (D0210) provided by an out-of-network provider on January 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the billed code was already paid. This code is only payable once per date of 
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. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, this code is considered a 
"per date of service" code and was already paid once for the date of service at issue. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (80307) provided December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis (74177) provided on October 26, 2021. 
 
You asked the Plan to pay for scan of the abdomen and pelvis. You say that you have provided documents to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the procedure code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our coder 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 scan of the abdomen and pelvis. Our 
reviewer says that the procedure code at issue does not meet criteria for reimbursement. Our coder reviewer 
found that the available documentation supports that the procedure was performed at the same time the 
comprehensive procedure coded 74174. In this case this procedure should be reported with procedure code 
74174. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of scan of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis (74177) 
provided on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bladder irrigation (51700) provided September 16, 2021. 
 
You asked the Plan to pay for the bladder irrigation. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable for this 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. 
 
We find that CPT code 51700 is not supported in the medical record. Specifically, the record shows a catheter 
removal was performed on the date of service. Irrigation is included in this service and is not separately 
reportable. Based on this information, we decided that Medicare rules for coverage of the bladder irrigation 
have not been met. Therefore, we decided that the Plan does not have to pay for a bladder irrigation (51700) 
provided September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening you had on January 6, 2022. 
 
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are 
covered at a frequency of once every 12 months for men who have attained age 50.  
 
We looked at the file and Medicare rules. The records do not show that you were 50 years old when the 
services were provided. Based on this information, we decided that Medicare rules for coverage of the 
screening have not been met. Therefore, we decided that the Plan does not have to pay for the prostate cancer 
screening you had on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment, limited, (D9951) provided on 
January 3, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied 
your request. The Plan says the occlusal adjustment, limited, is not listed as a covered service. 
 
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 occlusal adjustment, limited, is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal adjustment, limited, (D9951) provided on January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services rendered on March 23, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded and a status indicator of T represents a code that is only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. 
 
We looked at the file and Medicare rules. Billed procedure code P9037 (platelets, pheresis, leukocytes reduced, 
irradiated, each unit) has a status indicator of X and is statutorily excluded. Code 36592 (collection of blood 
specimen using established central or peripheral catheter, venous, not otherwise specified) has a status indicator 
of T and is not payable because it was not billed without other services payable under the physician fee 
schedule by the same provider. Therefore, we decided that the Plan does not have to pay for the outpatient 
services rendered on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the foot provided on March 11, 
2022 
 
You asked the Plan to waive the copayment for the X-rays. You say that you feel the X-rays should be included 
with the office visit. 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 $35 
copayment for X-rays provided in a specialist's office.  
 
You have been asked to pay $32.15, which is less than the $35 copayment for the X-rays. The X-rays 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 X-rays of the foot provided on March 11, 2022
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
January 6, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were not aware of any 
copayment at the time of the procedure. 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 $125 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $110.48, which is less than the $125 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 January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on August 13, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that the copayment is too high and should 
be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for each non-routine Medicare covered foot care visit. This is for diagnosis and the medical or 
surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs).  
 
You have been asked to pay $45 copayment for the podiatry office visit. The office visit falls within the 
Podiatry services - Medicare-covered 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 
office visit provided on August 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not informed of any 
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 $250 
copayment for outpatient surgery in an ambulatory surgical center or hospital outpatient facility.  
 
You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy 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 a diagnostic colonoscopy 
performed on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81311, 81162, 81301, and 
81206 provided on September 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 CPT codes 81311, 81162, 81301, and 81206 are not supported in the medical record. Specifically, 
the documentation shows that a Tempus panel was provided. When a laboratory assays two or more genes in an 
enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes one 
procedural service, so one code should be submitted for the entire panel. The file does not support that only one 
code was submitted for the panel. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81311, 81162, 81301, and 81206 provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency diagnostic oral exam (D0140) and intraoral x-
ray (D0220) provided on March 16, 2022. 
 
You asked the Plan to pay for the dental exam and x-rays. You say that these services were necessary and 
should be paid. The Plan denied your request. The Plan says these services were provided in a frequency that is 
not covered under your benefit. You previously received an intraoral x-ray on February 7, 2022, and an 
emergency oral exam on March 1, 2022, which were covered by the Plan. 
 
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 documentation supports that these 
services are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the emergency diagnostic oral exam (D0140) and intraoral x-ray (D0220) provided on 
March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology specialist office visit 
provided on February 8, 2022, and February 15, 2022.  
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you saw a physician's 
assistant and should not have a 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 $35 
copayment for a specialist office visit.  
 
According to the EOC, a cost sharing amount applies to specialist services from a physicians assistant. You 
have been asked to pay a $35 copayment for each specialist office visit on February 8, 2022, and February 
15,2022. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a dermatology specialist office 
visit provided on February 8, 2022, and February 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound provided on 
January 26, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the enrollee's doctor recommended 
the procedure. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment for ultrasounds.  
 
The enrollee has been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a transvaginal ultrasound provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - two surfaces, posterior (D2392) 
for teeth 15 and 16 provided December 28, 2021. 
 
You asked the Plan to pay for the resin fillings for back teeth. You say that the dental office told you that most 
of the procedures would be covered. The Plan denied your request. The Plan says this service is not covered 
under your benefits. The Plan also states that they have made an exception to cover the fillings as silver fillings 
and are providing partial reimbursement. 
 
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 pay for the resin-
based composites - two surfaces, posterior (D2392) for teeth 15 and 16 provided December 28, 2021.