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

 
We decided that the Plan does not have to reduce the copayment for a cardiology specialist visit and an 
ultrasound of the heart with continuous monitoring provided on August 27, 2021. 
 
You asked the Plan to reduce the copayment for a cardiology specialist visit and an ultrasound of the heart. 
You say that the doctor's billing office told you that these codes should have been combined, and you should 
only have one copayment. You also say that you should not be double billed since it was the same date and 
same visit for a single 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 $10 
copayment for radiological diagnostic services, including ultrasounds. The Plan contract also says that 
enrollees must pay a $30 copayment for a specialist office visit. 
 
The records show you had a specialist office visit and an ultrasound on August 27, 2021. Even though they 
were at the same office and on the same day, the ultrasound is a separately paid test and not included in the 
office visit. You have been asked to pay a $10 copayment for an ultrasound of the heart. An ultrasound of the 
heart falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You 
have also been asked to a $30 copayment for a cardiology specialist office visit. A cardiology specialist office 
visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. You 
have been asked to pay a total of $40 for a cardiology specialist office visit and an ultrasound of the heart ($30 
copayment + $10 copayment = $40). 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 reduce the copayment for a cardiology 
specialist visit and an ultrasound of the heart with continuous monitoring provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 27, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship with the 
ordering provider. 
 
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 office visit (99202) provided on 
January 27, 2021. have been met. Specifically, the documentation submitted does not include sufficient clinical 
information to verify CPT code 99202. Additionally, the record does not include any evidence of an established 
relationship between the enrollee and ordering physician. Therefore, we decided that the Plan does not have to 
pay for the office visit (99202) provided on January 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43239). 
 
You asked the Plan to pre-approve the EGD. You say that you find this service to be medically necessary. The 
Plan denied your request. The Plan says the criteria for approval of an EGD have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the esophagogastroduodenoscopy 
(EGD). Our reviewer says that the requested EGD is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that you have Barrett's esophagus without dysplasia 
demonstrated by EGD in January 2021. Our reviewer found that the record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested EGD. Our physician 
reviewer also found that the elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Charlotte Plush Euro-top mattress, adjustable base, 
delivery, and sales tax purchased on October 30, 2021. 
 
You asked the Plan to pay for the Charlotte Plush Euro-top mattress, adjustable base, delivery, and sales tax. 
You say that the items/services were medically necessary. The Plan denied your request. The Plan says these 
items/services were obtained through a provider that does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Charlotte Plush Euro-top mattress, 
adjustable base, delivery, and sales tax purchased on October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve two resin-based composites (D2331 x2) and a simple extraction 
(D7140). 
 
You asked the Plan to pre-approve the resin-based composites and simple extraction. You say that you are 
unable to eat and drink due to the severe pain you are experiencing. The Plan denied your request. The Plan 
says that these services are not covered under your benefit plan. 
 
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 submitted an Office Reference Manual (ORM) which includes 
exhibits from numerous dental packages offered by the Plan. The file does not specify which exhibit 
corresponds to the enrollees coverage. Review of the product names for the various dental packages does not 
clearly indicate which package corresponds to the enrollees coverage. As such, we are not able to determine 
which dental plan listed describes the enrollees benefits. Without this information, we find that the Plan has 
not substantiated its denial of the services at issue. Therefore, we decided that the Plan has to pre-approve two 
resin-based composites (D2331 x2) and a simple extraction (D7140).  
 
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 waive the copayment for a skin lesion removal procedure provided 
on August 24, 2021. 
 
You asked the Plan to waive the copayment for a skin lesion removal procedure. You say that you were 
charged a hospital surgical fee since the billing is done by the affiliated hospital. You also say it was a routine 
biopsy performed in a clinic. 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 $150 
copayment for outpatient hospital surgery services.  
 
 A skin lesion removal procedure is considered a surgical procedure. The records show the procedure was 
performed at a hospital. You have been asked to pay a $150 copayment for a skin lesion removal procedure. A 
skin lesion removal procedure 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 skin lesion removal procedure provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided from 
August 30, 2021, to September 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you would like to appeal for 
retroactive authorization based on medical necessity. The Plan denied your request. The Plan says this provider 
is a non-network provider who does not work with the Plan and the member was referred by his non-
participating nursing facility. The Plan also says that the member's primary care physician (PCP) did not refer 
for services and no medical necessity for an out-of-network provider, such as an urgent or emergency situation, 
has been documented. The Plan also says that alternate network providers were found. 
 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 subsequent nursing facility care (99308) provided 
from August 30, 2021, to September 6, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diapers (A4520), provided on November 19, 2021. 
 
You asked the Plan to pay for incontinence supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the diapers (A4520), provided on 
November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no established relationship between the 
enrollee and ordering provider. 
 
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 office visit (99202) provided on 
February 11, 2021. have been met. Specifically, the documentation submitted does not include sufficient 
clinical information. Additionally, there is no evidence of an established relationship between the enrollee and 
ordering physician. Therefore, we decided that the Plan does not have to pay for the office visit (99202) 
provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81455). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Molecular pathology procedures (Tier1 and Tier 2) 
may be eligible for coverage when testing assay(s) are Food and Drug Administration (FDA) approved. 
 
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 genetic testing. Our reviewer says 
that the requested genetic testing is not medically necessary. Our physician reviewer found there is no 
indication that the testing at issue for this enrollee is FDA-approved, or that there has been a technical 
assessment completed. It has not been demonstrated that the results of the genetic testing will directly impact 
the management of 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81455).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on May 18, 2021, 
through June 11, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the HIPPS code should be what was 
approved in the authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans must make reasonable and 
diligent efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have been met. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request. We find that the Plan did not 
submit a compelling denial rationale in this case. The claim was denied due to lack of authorization for the 
SNF services. However, the Plan has attested that the SNF services were authorized with a HIPPS code that 
was calculated at the time that the approval was requested. Based on how the HIPPS code is calculated, 
however, it is not reasonable to expect or require that the code requested for authorization be the code that is 
billed. The HIPPS code billed must correspond to the enrollees actual condition and the services actually 
rendered during the statement period of the claim. It would therefore be expected that the billed code would 
differ from a code that was estimated prior to the services being rendered. The Plan has not made any argument 
that any of the digits of the billed HIPPS code are incorrect or not supported, only that the code, as a whole, 
was not approved. We find that this denial of payment has not been substantiated. Therefore, we decided that 
the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on May 18, 2021, through June 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 21, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the Plan paid the maximum eyewear benefit amount of $190. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear benefit 
amount of $190. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses 
provided on June 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on 
November 17, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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 ultrasound of the abdomen (76705) provided on November 
17, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring (G0453) 
provided on October 4, 2021. 
 
You asked the Plan to pay for continuous intraoperative monitoring. You say that these services were 
necessary, provided in-network, and billed appropriately. The Plan denied your request. The Plan says that this 
is a split service that represents a portion of the units from the originally submitted service. 
 
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. Specifically, the Plan has not sent the original claim and they have not provided 
any evidence to substantiate or clarify their denial. Therefore, we decided that the Plan has to pay for 
continuous intraoperative neurophysiology monitoring (G0453) provided on October 4, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 10, 2020, to August 19, 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 payment of DRG 871 is not supported, as the review supports a DRG of 193. 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 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS 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 enrollee was admitted and treated for pneumonia and associated shortness of 
breath based on x-ray findings. She was reported to be "ill-appearing" but alert and oriented. The enrollee was 
hemodynamically stable and had no evidence of a systemic severe infection. Therefore, the more appropriate 
DRG is 193 (simple pneumonia and pleurisy with MCC) as there was insufficient support for DRG 871 
(septicemia or severe sepsis without MV >96 hours with MCC) as there was no evidence of end-organ damage 
in the setting of a systemic infection.  
 
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 August 10, 2020, to August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on October 6, 2021. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says vision care services 
and supplies are excluded from coverage under your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear.  
 
The services you asked the Plan to pay for are considered routine eyewear. Therefore, we decided that the Plan 
does not have to pay for eyeglasses provided on October 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on November 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the ultrasound provided on November 15, 2021, by an out-of-
network (OON) provider.