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

 
We decided that the Plan does not have to pay for the laboratory services (85060) provided on January 19, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment based on medical necessity. The Plan denied your request. The Plan says the place of 
service billed is not an appropriate place of service for code 85060 according to Medicare billing rules. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The records 
show that the services were not performed in the inpatient setting. 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 (85060) provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an out-
of-network (OON) provider from November 23, 2021, to December 1, 2021. 
 
You asked the Plan to waive the copayment for the OON inpatient care. You say that you should only be 
responsible for a $25 emergency room 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 $345 per 
day for days 1-5 and $0 per day for days 6-365 for each inpatient admission at an out-of-network facility.  The file shows that you were in the hospital from November 23, 2021, to December 1, 2021. Therefore, you 
have been asked to pay $345 per day for the first 5 days of OON inpatient care. The total for your stay is 
$1,725 ($345 copayment x 5 days = $1,725). The OON inpatient care falls within the 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 copayment for inpatient hospital care provided 
by an out-of-network (OON) provider from November 23, 2021, to December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for doppler echocardiography provided to the enrollee on 
October 14, 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 these services are not separately reportable by the physician performing a transcatheter aortic 
valve replacement. 
 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 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
CPT 93325: 
 
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
echocardiography) 
 
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 that these two codes are add-on 
procedure codes, and would not be reported separately from a transcatheter aortic valve and mitral valve 
replacement procedure. 
 
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 doppler echocardiography provided to the enrollee on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical and injection services provided to the enrollee on 
June 26, 2019. 
 
 
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 records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 58300: 
 
Insertion of intrauterine device (IUD) 
 
HCPCS C1889: 
 Implantable/insertable device, not otherwise classified 
 
HCPCS J2370: 
 
Injection, phenylephrine hcl, up to 1 ml 
 
HCPCS J2704: 
 
Injection, propofol, 10 mg 
 
HCPCS J7042: 
 
5% dextrose/normal saline (500 ml = 1 unit) 
 
HCPCS J7120: 
 
Ringers lactate infusion, up to 1000 cc 
 
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 that in terms of CPT 58300, the 
operative report describes myringotomy and tube placement.  In this case, there is a more appropriate code to 
report for this service. Therefore this procedure code cannot be verified. The other codes are incidental to the 
primary procedure, when it is billed correctly. 
 
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 and injection services provided to the enrollee on June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 20, 
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 Current Procedural Terminology (CPT) code 33286-59 (1 Unit) remains not supported. 
 
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 33286 is "Removal, subcutaneous cardiac rhythm 
monitor." 
 
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 that the procedure report describes 
"Implantation of a loop monitor, and extraction of old loop monitor" on the same date of service and during the 
same session. In this case services were reported incorrectly, as CPT codes 33285 and 33286 would only be 
reported together with modifier 59 (or modifier XE) if for some reason the old monitor was removed during 
one encounter and the new monitor was inserted at a separate encounter later on the same day.  
 
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 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on February 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained by a participating provider. 
 
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 physical therapy provided on February 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 13, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the provider in this case has not billed 
as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on December 13, 2021, have been met. In this case, medical records from the enrollees ordering provider were not received to indicate the medical necessity and reasonableness of the ordered testing. Therefore, we decided 
that the Plan does not have to pay for the genetic testing services provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on June 23, 
2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the exam was routine 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 $40 
copayment for each eye exam service.  
 
The file shows that the provider billed the exam as diagnostic. Therefore, you have been asked to pay a $40 
copayment for the eye exam. The eye exam falls within the Vision 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 copayment for a diagnostic eye exam provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower transfer bench (E0247). 
 
You asked the Plan to pay for a shower transfer bench. You say that this item is not for comfort and 
convenience, it is a necessity. The enrollee cannot lift his legs over the side of the tub to get in the shower. It is 
hard enough to get into the shower with the bench, it is impossible without it. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower transfer bench (E0247).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for open or surgical arthroscopic procedures of the elbow 
(01740) provided January 21, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the service you have reported is an 
anesthesia service rendered by a Certified Registered Nurse Anesthetist. Please review and have specialty 
updated in the system to reflect the correct specialty for services rendered. The Plan denied your request. The 
Plan says that ASA codes are only reimbursed to anesthesia providers only. Therefore, this code is not eligible 
for payment. 
 
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 provided a valid reason for why a nurse anesthetist would not be 
appropriate to provide the services at issue in this case. Therefore, we decided that the Plan has to pay for the 
anesthesia for open or surgical arthroscopic procedures of the elbow (01740) provided January 21, 2022.  
 
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 anesthesia services provided to the enrollee on October 1, 
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 this code has a status indicator of "B." 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services provided to the enrollee on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the gallium injection on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the gallium injection. You say that you were told by the 
provider to only pay the other copay amount. The Plan denied your request. The Plan says the cost-sharing you 
are being charged 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 each Medicare-covered medical supply.  
 
  You have been asked to pay $738.90, which is 20% of the allowed amount for the gallium injection. The 
allowed amount is $3,684.50 (20% x $3,684.50 = $738.90). The gallium injection falls within the Outpatient 
Diagnostic Test 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 coinsurance for the gallium injection on January 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (CPT code 71045) provided on August 6, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 71045 is supported in the medical record. Review of the records show two different x-
rays were performed in the same day. One chest x-ray was performed during the bronchoscopy and the second 
chest x-ray was performed post bronchoscopy. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for the chest x-ray 
(CPT code 71045) provided on August 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 8, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe these services should be covered. The 
Plan denied your request. The Plan says services provided out-of-network are not covered. 
 
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. The Plan covers covered 
dental services when the services are provided by an in-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from November 6, 
2021, to November 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this was not medically necessary and there was no authorization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented with shortness of breath and a fall. Evaluation in the Emergency 
Department after treatment during ambulance transport revealed blood pressure 135/83, pulse 73, respirations 
18 and pulse of 99 %. There was significant wheezing on examination. The patient was admitted for 
intravenous Solu-medrol, Duonebs, oxygen supplementation as needed. After the first midnight's time of care, 
the patient has persistent wheezing on examination and treatment with Solumedrol and nebulizer therapy was 
continued. The record does show that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from November 6, 2021, to November 9, 
2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee is able to control the power options using their own switches. The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pre-approve the requested items. Our physician reviewer found that in this case, the enrollee has a 
neurologic disorder with functional deficits. The requested expandable control system is not medically 
necessary as the enrollee does have use of his upper extremities. He can operate and control the power options 
using the switches that are included in the basic wheelchair. 
 
The file shows that a power seat elevation system was requested. This feature is non-covered because it is not 
primarily medical in nature. We looked at the physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, 
we decided that the Plan does not have to pre-approve power wheelchair accessories.