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

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 9, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the attached reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment is denied because it is bundled to another 
service billed on the same day by the same provider.  
 
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 the CT scan (70450) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99215) provided on January 
3, 2022. 
 
You asked the Plan to waive the copayment for the office visit. 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 $20 
copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist visits.  
 
You have been asked to pay a $20 copayment for the specialist office visit. 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 office visit (99215) provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystoscopy provided on February 18, 
2022. 
 
You asked the Plan to waive the copayment for the cystoscopy. You say that the copayment for the procedure 
should be waived since you were also charged for an office visit. The Plan denied your request. The Plan says 
the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 per 
day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic 
endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.  
 
 
  You have been asked to pay $350 for the cystoscopy. The cystoscopy 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 the cystoscopy provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $350 copayment for an MRI performed on February 6, 
2022. 
 
You asked the Plan to waive the $350 copayment for an MRI performed on February 6, 2022. You say that this 
copayment is very high, and you cannot afford this copayment. The Plan denied your request. The Plan says 
you are responsible to pay a $350 copayment for an MRI performed on February 6, 2022. 
 
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 $350 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $350 copayment for an MRI performed on February 6, 2022. An MRI 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 $350 copayment for an MRI performed on February 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 22, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was medically necessary and is supported 
as billed. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not note the 
time spent providing this service on the date in question. Based on this information, we decided that Medicare 
rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care, first hour (99291) provided on December 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient skilled nursing facility (SNF) 
care provided from December 14, 2021, through February 17, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that she must pay 
a $0 copayment per day, for days 1-20 and a $184 copayment per day, for days 21-100 for skilled nursing 
facility care.  
 
The enrollee has been asked to pay $4,968 ($184 copayment x 27 days) for the skilled nursing facility care 
provided. 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 copayments for the inpatient skilled nursing facility (SNF) 
care provided from December 14, 2021, through February 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the office visit provided on April 5, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you saw your primary care doctor 
and should only be charged a $5 copayment not a $25 copayment. The Plan denied your request. The Plan says 
that the copayment applied is correct. 
 
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 must pay $5 copayment for each primary care physician visit for 
Medicare-covered benefits. 
 
The Plan says you must pay $25 copayment for specialist office visit. However, this provider was a family 
doctor which is considered a primary care physician. Therefore, we decided that the Plan has to reduce the 
copayment for the office visit provided on April 5, 2022, from $25 to $5.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a supply allowance provided on March 29, 
2022. 
 
You asked the Plan to waive the coinsurance for a supply allowance. You say that you live alone and have lots 
of trauma in your life and cannot afford the cost. The Plan denied your request. The Plan says you have been 
charged the correct coinsurance 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 20% 
coinsurance for covered items which include, but are not limited to: wheelchairs, crutches, powered mattress 
systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech 
generating devices, oxygen equipment, nebulizers, and walkers.  
 
 
 You have been asked to pay $46.92, which is 20% of the allowed amount for the supply allowance. The 
allowed amount is $234.60 (20% x $234.60 = $46.92). The supply allowance falls within the Durable medical 
equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a 
supply allowance provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on December 22, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is not 
appropriate to bill an additional inpatient hospital visit. 
 
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 99221 was previously billed and paid for by the Plan. CPT code 99221 may be reported 
only once per day by the same physician. 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 the 
inpatient hospital care provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a vest with a built-in heart pacing device 
that includes a heart event recorder, provided from January 6, 2022, to April 6, 2022. 
 
You asked the Plan to waive the coinsurance for a vest with a built-in heart pacing device. You say that you 
weren't aware there would be a cost share and you cannot afford to pay it. The Plan denied your request. The 
Plan says the coinsurance 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 20% 
coinsurance for advanced DME and related supplies.  
 
 
 
 You have been asked to pay $2,464.76 which is 20% of the allowed amount for a vest with a built-in heart 
pacing device for four months. The allowed amount is $3,080.95(20% x $3,080.95=$616.19) ($616.19 x 4 
months = $2,464.76). A vest with a built-in heart pacing device falls within the Durable medical equipment 
(DME) and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a vest with 
a built-in heart pacing device that includes a heart event recorder, provided from January 6, 2022, to April 6, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit (99285) provided on August 13, 
2021. 
 
You asked the Plan to pay for the critical care service. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room visit (99285) provided on August 13, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rituximab. 
 
You asked the Plan to pre-approve rituximab. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has been stable on Humira. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 rituximab. Our reviewer says that the 
requirements for coverage of rituximab have not been met. Our physician reviewer found there is no 
documentation that the rituximab (without concomitant methotrexate administration) is medically reasonable 
and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rituximab have not been met. Therefore, we decided that the Plan does not have 
to pre-approve rituximab.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on January 
14, 2022, and February 11, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that in 2021 you were only 
charged a $10 copayment and that's all you should have to pay now. The Plan denied your request. The Plan 
says the copayments applied are 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 $35 
copayment for per provider per day for each Medicare covered physical therapy or speech therapy visit. 
 
You have been asked to pay a total of $70 ($35 x 2 visits) copayment for physical therapy visits. Physical 
therapy visits fall within the Outpatient rehabilitation services 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 physical therapy visits provided on January 14, 2022, and February 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on January 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
psychotherapy. We found no exception that would require the Plan to pay for the psychotherapy. The records 
provided for review do not show that psychotherapy was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy provided on January 6, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a 1-month rental of the requested transcutaneous electrical nerve 
stimulation (TENS) device. 
 
You asked the Plan to pre-approve a 1-month rental of the requested TENS device. You say that this device is 
medically necessary following the enrollee's surgery. The Plan denied your request. The Plan says that the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TENS is covered for acute post-operative pain. 
Coverage is limited to 30 days (one month's rental) from the day of surgery. 
 
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 1-month rental of the requested TENS 
device. Our reviewer says that the requested TENS device is medically reasonable and necessary based on 
Medicare coverage criteria. Our physician reviewer found the enrollee is a 66-year-old woman who underwent 
a left total shoulder replacement on April 28, 2022 and had a TENS unit prescribed. The LCD covers TENS for 
an acute post-operative pain. The request for a TENS device was made within 30 days from the enrollees date 
of surgery. Although the Plan waited until after the 30 days had expired to make their decision, the criteria for 
coverage had been met at the time of the request and was within the appropriate timespan for coverage. 
 
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 1-month rental of the requested TENS device have been met. Therefore, we 
decided that the Plan has to pre-approve a 1-month rental of the requested transcutaneous electrical nerve 
stimulation (TENS) device.  
 
 
 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 the selective catheter placement (36226) and aortography 
(75605) provided on October 20, 2021.l 
 
You asked the Plan to pay for the selective catheter placement (36226) and aortography (75605). You say that 
the radiology records support the services billed and the denied charges should be reprocessed correctly. The 
Plan denied your request. The Plan says procedure code 36226 is not supported by the medical records 
submitted. The Plan also says procedure code 75605 is inclusive to procedure code 36223. 
 
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 36226 is selective catheter placement, vertebral artery, 
unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision 
and interpretation, includes angiography of the cervicocerebral arch, when performed. The CPT Code Manual 
definition of code 75605 is aortography, thoracic, by serialography, radiological supervision and interpretation. 
 
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 selective catheter placement (36226) and aortography 
(75605). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found the operative report does not include documentation to support a selective 
catheter placement. In this case, CPT code 36226 cannot be verified. CPT code 75605 would be inclusive to 
CPT 36226 and would not be reported separately. Therefore, this procedure would not be covered since CPT 
code 36226 is not supported by the medical record. 
 
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 selective catheter placement (36226) and aortography (75605) have not been 
met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36226) and 
aortography (75605) provided on October 20, 2021.l
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for a knee injection received on February 
21, 2022. 
 
You asked the Plan to waive the $250 copayment for a knee injection received on February 21, 2022. You say 
that you did not know you were going to have a $250 copayment. The Plan denied your request. The Plan says 
you are responsible to pay a $250 copayment for procedures/surgery at an outpatient hospital. 
 
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, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $250 copayment for a knee injection. A knee injection 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 $250 copayment for a knee injection received 
on February 21, 2022.