Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visits provided on January 13, 
2022, and January 20, 2022. 
 
You asked the Plan to waive the copayment for urgent care visits. You say that the primary care doctor told you 
to call urgent care so it should be covered. 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 $50 
copayment for each urgent care visit. 
 
 
 
 
 
 You have been asked to pay a total of $100 copayment for the urgent care visits. Urgent care visits fall within 
the Urgently needed 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 urgent care 
visits provided on January 13, 2022, and January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrosurgical resection of prostate (52601) provided on 
May 14, 2021. 
 
You asked the Plan to pay for the electrosurgical resection of prostate (52601). You say that the diagnosis 
codes were previously corrected as these were two separate locations, and the records support the coding. The 
Plan denied your request. The Plan says procedure code 52235 was approved, and procedure code 52601 is not 
supported by the medical records submitted. 
 
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 52601 is transurethral electrosurgical resection of 
prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, 
urethral calibration and/or dilation, and internal urethrotomy are included).  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 electrosurgical resection of prostate (52601). 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 enough documentation to confirm all criteria per the CPT 
code description have been completed. In this case, there is a more appropriate code to report. 
 
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 electrosurgical resection of prostate (52601) have not been met. Therefore, 
we decided that the Plan does not have to pay for the electrosurgical resection of prostate (52601) provided on 
May 14, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the omental flap (49905). We decided that the Plan does not have to 
pay for the blood vessel repair (35221).  
 
You asked the Plan to pay for the blood vessel repair (35221) and omental flap (49905). The Plan says that 
procedure code 35221 is inclusive to procedure code 47122 and procedure code 49905 is not supported by the 
medical records submitted. 
  We decided that the Plan has to pay for the omental flap (49905).  
 
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 the omental flap (49905). Our reviewer says that the documentation 
submitted was reviewed and does meet the criteria for coverage. Our reviewer found that the operative report 
describes omental flap for defect. The Omentum was mobilized off the right colon and laid as an omental flap 
along the cut edge of the liver. Therefore, we decided that the Plan has to pay for the omental flap (49905).  
 
We also decided that the Plan does not have to pay for the blood vessel repair (35221). 
 
Our reviewer says that the documentation does not meet the criteria for coverage. Our reviewer found that the 
portal vein repair would be included with the resection of liver as these are the same organ system and would 
not be reported separately. Therefore, we decided that the Plan does not have to pay for the blood vessel repair 
(35221). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on February 5, 
2022. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that you have provided medical records to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is included in another billed code. 
 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 an abdominal ultrasound (76705) provided on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that it is more convenient to stay with this physician than to find a new PCP. The Plan 
denied your request. The Plan says you must choose a Plan provider to be your primary care physician and 
there are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36215) and venography 
(75827) provided on March 10, 2021. 
 
You asked the Plan to pay for the selective catheter placement (36215) and venography (75827). You say that 
the medical records should be reviewed, and all the procedure codes billed reprocessed to pay. The Plan denied 
your request. The Plan says procedure code 36215 is not supported by the medical records submitted and 
procedure code 75827 is considered inclusive to CPT code 37248. 
 
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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. In this case, the CPT Code 
Manual definition of code 75827 is venography, caval, superior, with 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 (36215) and venography 
(75827). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found the procedure report does not include enough information to confirm guidelines 
for CPT code 36215 have been met. In addition, CPT code 75827 would be inclusive to CPT 37248 per the 
code description. 
 
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 (36215) and venography (75827) have not been 
met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36215) and 
venography (75827) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on January 10, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
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 Home Health Services provided on January 10, 
2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right sacroiliac joint fusion surgery. 
 
You asked the Plan to pre-approve right sacroiliac joint fusion surgery. You say that the clinical information 
provided supports the need for the requested surgery. You say that the requested surgery is medically 
necessary, warranted, and indicated. The Plan denied your request. The Plan says there is insufficient evidence 
in peer reviewed journals to support the clinical utility of a sacroiliac joint fusion. 
 
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 right sacroiliac joint fusion surgery. 
Our reviewer says that right sacroiliac joint fusion surgery is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is being treated for low back pain. He 
presented with persistent right lumbosacral pain greater than right lower extremity pain. He noted significant 
improvement in his right-sided lumbosacral pain for a short duration following the sacroiliac (SI) joint 
injection. The exam reveals restricted lumbar range of motion by about 50%. Fortins finger, FABER, and 
thigh thrust are all positive. Reflexes are diminished throughout. However, there is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Multiple other plausible pain generators including at the lumbosacral spine are evident. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested sacroiliac joint fusion, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right sacroiliac joint fusion surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right sacroiliac joint fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is unable to stand, walk, or 
keep her balance. The Plan denied your request. The Plan says the enrollee does not have an absence of non-
facet pathology. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the enrollee has a history of chronic pain syndrome, chronic bilateral low back pain, 
lumbar spinal stenosis, lumbar radiculopathy, lumbar spondylosis, and post-laminectomy syndrome, posterior 
lumbar interbody fusion. Magnetic resonance imaging revealed severe spinal stenosis at L2-L3, and spinal 
stenosis at L4-L5 and L3-L4 related to facet arthropathy and spondylolisthesis. In this case, there is no non-
facet pathology per clinical assessment or radiology studies that could explain the source of the enrollees pain.  
Therefore, the requested facet joint injections are not considered medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that this charge 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 $295 
copayment for Medicare covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay $295 copayment for an injection. Injections fall within the Outpatient Surgery and 
Other Medical 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 an injection provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on October 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this service does 
not meet the coverage requirements in the applicable LCD or NCD. 
 
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 argues that the LCD or NCD coverage criteria are not met. However, 
the Plan has not provided the applicable LCD or NCD for review, nor has the Plan referenced which coverage 
criteria have not been met. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services provided on October 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 15 to August 12, 2021. 
 
You asked the Plan to pay for medical services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 medical services provided on June 15 
to August 12, 2021. have been met. No medical records have been made available for review to determine the 
medical necessity of the medical services provided to the enrollee. Therefore, we decided that the Plan does not have to pay for medical services provided on June 15 to August 
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmology visit provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you cannot afford the 
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 $45 
copayment for each visit to diagnose and/or treat a disease or condition of the eye.  
 
You have been asked to pay a $45 copayment for the ophthalmology visit. The ophthalmology visit 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 an ophthalmology visit 
provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 84228, G0480 and 82542 
provided on February 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization. You conducted in good faith the laboratory testing ordered by the referring 
provider, who deemed the services to be medically necessary. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 the laboratory services coded as 84228, G0480 
and 82542 provided on February 10, 2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (ECG) provided on May 
5, 2021. 
 
You asked the Plan to waive the copayment for ECG. You say that the ECG should be covered under the office 
visit charge. 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 $10 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).  
 
 
 
 You have been asked to pay $10 copayment for ECG. ECG 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  
ECG provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on January 
14, 2022. 
 
You asked the Plan to pay for the computed tomography. 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 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 computed tomography coded 70450 provided on January 14, 
2022.