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

 
We decided that the Plan does not have to pay for cystourethroscopy, with insertion of indwelling ureteral stent 
and cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or 
renal pelvic lesion provided on June 14, 2023. 
 
You asked the Plan to pay for cystourethroscopy, with insertion of indwelling ureteral stent and 
cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal 
pelvic lesion. You say that this patient was treated for left ureteral cancer. You say the patient was found to 
have microhematuria and this treatment was medically necessary. The Plan denied your request. The Plan says the cystourethroscopy, with insertion of indwelling ureteral stent and cystourethroscopy, with ureteroscopy 
and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion is not medically necessary. 
 
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 pay for cystourethroscopy, with insertion of 
indwelling ureteral stent and cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or 
fulguration of ureteral or renal pelvic lesion. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found a cystourethroscopy on 
December 29, 2022 showed high grade papillary carcinoma in the left ureter which was positive for expression. 
Computed tomography scan from April 26, 2023 showed left periureteric soft tissue thickening of the proximal 
to mid ureter resulting in mild to moderate hydroureteronephrosis concerning for urothelial neoplasm. It is 
unclear what additional information was/would be gained from the procedure on June 14, 2023, that was not 
already present in the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystourethroscopy, with insertion of indwelling ureteral stent and 
cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal 
pelvic lesion have not been met. Therefore, we decided that the Plan does not have to pay for 
cystourethroscopy, with insertion of indwelling ureteral stent and cystourethroscopy, with ureteroscopy and/or 
pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion provided on June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a second in-network acute inpatient stay 
provided from June 6, 2023, to June 13, 2023. 
 
You asked the Plan to waive the copayment for a second in-network acute inpatient stay. You say that you had 
to be transferred from one hospital to another because the first one could not do the testing you needed. For this 
reason, you feel you should not need to pay for a second copayment. The Plan denied your request. The Plan 
says this cost sharing was charged 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).  The enrollees contract with the Plan clearly says that enrollees must pay a $395 copayment per day, for days 1 
to 5 for inpatient hospital care.  
 
The enrollee has been asked to pay a $1975 total copayment for a second in-network acute inpatient stay. This 
item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a second in-network acute inpatient stay provided from June 6, 2023, to June 
13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiogram provided on May 30, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the echocardiogram. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this service is not covered when received by an 
out-of-network 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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient diagnostic testing is not covered 
 
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. 
Therefore, we decided that the Plan does not have to pay for the echocardiogram provided on May 30, 2023, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy procedure provided on May 
11, 2023. 
 
You asked the Plan to waive the copayment for an endoscopy procedure. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 a $285 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $285 copayment for an endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 endoscopy procedure provided on May 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the speech therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the speech therapy services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the speech therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (20985) provided on May 31, 
2023. 
 
You asked the Plan to pay for surgical assistant services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the base service was non-covered, therefore the surgical assistant 
service is not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20985. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services (20985) provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99222) 
rendered on November 19, 2022. 
 
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 documents do not support this level of care. 
 
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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, or that 50 
minutes or more were spent. 
 
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 evaluation and management services (procedure code 99222) rendered on November 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on June 20, 2023, by an out-
of-network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
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 home health visit provided on June 20, 2023, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 14302 provided on May 11, 2023. 
 
You asked the Plan to pay for procedure code 14302. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid primary 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 procedure code 14302 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 14302 provided on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45380 and 43239 provided on April 17, 
2023. 
 
You asked the Plan to pay for procedure codes 45380 and 43239. You say that the medical records support the 
use of the XS modifier with procedure codes 45380 and 43239. The Plan denied your request. The Plan says 
the services are not covered 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 45380 is a column II code to column I code 45385, and code 43239 is 
a column II code to column I code 43249; however, procedure codes 45380 and 43239 were billed with a 
modifier.  
 
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 procedure codes 45380 and 43239. Our reviewer says that 
the medical records do not support the use of the XS modifier with procedure codes 45380 and 43239. Our 
reviewer found for procedure code 45380, the procedure report does not support as a separate structure from 
procedure code 45385, and therefore cannot be verified. This procedure would be inclusive to the more 
comprehensive procedure, and not reported separately. 
 
For procedure code 43239, the procedure report does not support as a separate structure from procedure code 
43249, and therefore cannot be verified. This procedure would be inclusive to the more comprehensive 
procedure, and not reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 45380 and 43239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 45380 and 43239 provided on April 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure codes 97116, 97530, and 97535 
rendered from March 2, 2023, to March 29, 2023. 
 
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 97116: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)  
CPT 97530: 
 
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional 
performance), each 15 minutes 
 
CPT 97535: 
 
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal 
preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) 
direct one-on-one contact, each 15 minutes 
 
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 medical record describes that 
the physical therapist performed therapeutic services in the patient's home for these dates of service. There is a 
more appropriate to use in this situation. Additionally, these codes are timed procedures. The therapy notes do 
not include documentation of therapeutic activities each 15 minutes. 
 
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 therapy services (procedure codes 97116, 97530, and 97535 rendered from March 2, 2023, to 
March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive sacroiliac (SI) joint fusion 
procedure (27279). 
 
You asked the Plan to pre-approve SI joint fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability fracture or lesion. SI joint fusion for degenerative back pain is 
experimental.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a minimally invasive sacroiliac (SI) joint fusion procedure (27279).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services on 
April 21, 2023, to April 30, 2023. 
 
You asked the Plan to waive the copayment for SNF services. You say that you don't believe this charge is 
correct and that the attached documents support this claim. The Plan denied your request. The Plan says this 
cost sharing was charged 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 a $50 
copayment for each day 21 to 70. The Plan applied a $50 copayment to each day 40 to 50 (10 days) for a total 
copayment of $500 ($50 x 10 = $500) for Skilled Nursing Facility (SNF) Care.  
 You have been asked to pay a $50 copayment for each day 21 to 70. The Plan applied a $50 copayment to each 
day 40 to 50 (10 days) for a total copayment of $500 ($50 x 10 = $500) for Skilled Nursing Facility (SNF) 
Care. This item/service falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) services on April 21, 2023, to April 30, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99284 billed for date of service March 23, 2023. 
 
You asked the Plan to pay for code 99284. You say that this claim was coded correctly. The Plan denied your 
request. The Plan says that code 99284 is not supported by the medical records. The presenting problem was 
not a high risk threat. As a result, this claim was down-coded and paid at the 99283 rate. 
 
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 99284 is  Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. 
 
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 code 99284. Our reviewer says that code 99284 was 
supported by the medical record. Our reviewer found the enrollee was a 74-year-old male who presented to the 
emergency room requesting to be admitted for alcohol detox. On arrival he was tachycardic at 107. He was 
agitated on exam and his labs were relatively unremarkable. The enrollee was given saline, Ativan and Zofran. 
His vital signs and agitation improved on reassessment. He was discharged as he did not meet admission 
criteria and he was prescribed Librium. The enrollee presented with acute alcohol withdrawal requiring high 
risk IV medication (Ativan). He was given medication and reassessed. A detailed history and physical exam 
were performed. He was discharged with a prescription for a high-risk medication. As a result, the 
documentation supports procedure code 99284. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99284 have been met. Therefore, we decided that the Plan has to pay for 
code 99284 billed for date of service March 23, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on 
May 8, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on May 
8, 2023.