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

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 92921. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 92921 is considered bundled 
and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92921 billed for date of service October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and the urine test provided on January 25, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and the urine test. You say that you cannot afford to pay for these 
services. The Plan denied your request. The Plan says you must receive your 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 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 
items/services 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 office visit, and the urine test provided on 
January 25, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on October 1, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient on the date of service at issue.  Therefore, we decided that the Plan does not have to pay 
for the ambulance services provided on October 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 24, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on 
October 10, 2022. 
 
You asked the Plan to pay for the positron emission tomography (PET) scan. You say that you would like the 
Plan to reconsider their denial of payment. 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 PET scans must be billed with modifier PI or PS, 
if appropriate, to indicate initial or subsequent treatment strategy. 
 
We looked at the file, the claim, and Medicare rules. In this case, procedure code 78608 on the claim submitted was not billed with the appropriate PI or PS modifier. Therefore, we decided that the Plan does not have to pay 
for the positron emission tomography (PET) scan provided on October 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the aflibercept injection provided on 
December 21, 2022. 
 
You asked the Plan to reduce the coinsurance for the aflibercept injection. You say that this charge is high than 
normal for this injection. 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 10% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 10% coinsurance for the aflibercept injection. This item/service falls within the in-
network Medicare Part B drugs 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. The total you owe is $180.60 ($1,805.99 allowed amount  x 10% coinsurance = 
$180.60). Therefore, we decided that the Plan does not have to reduce the coinsurance for the aflibercept 
injection provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  in-network Orencia injections provided 
on February 13, 2023. 
 
You asked the Plan to waive the coinsurance for  in-network Orencia injections. You say that you cannot afford 
this coinsurance amount every time you have an injection done. You will be on these injections for the rest of 
your life. 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have a coinsurance of 20% for this service. This has resulted in a $848.32 coinsurance ($4242.06 x 20% 
coinsurance = $848.21). You have been asked to pay an $848.21 coinsurance for in-network Orencia injections. This item/service falls 
within the Medicare Part B drugs 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  
in-network Orencia injections provided on February 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that 
this is not medically necessary. Our physician reviewer found the record indicates snoring and daytime 
sleepiness, and the plan is for a "home sleep study". There is no complete sleep history, with no mention of 
observed apneas or symptoms related to parasomnias. There is no Epworth sleepiness score. The enrollee is not 
obese. No neck circumference measurement is provided.  An attended sleep study is apparently not what was 
intended by the ordering physician, and Medicare criteria are not met because of the incomplete sleep history. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
January 31, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning . You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says your tooth must have noticeable bone loss or show on 
an x-ray that there is a hard substance built up on the root of the tooth. Your x-rays do not show that you have 
these issues. 
 
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 deep gum and 
root cleaning when the services are medically necessary and reasonable.  
 
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 deep gum and root cleaning. Our reviewer says that the service is not medically necessary. Our physician reviewer found as there are less than 
four teeth in any quadrant with a showing of attachment loss, the requested four quadrants of scaling and root 
planing under D4341 would not be reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of deep gum and root cleaning have not been met. Therefore, we decided that the 
Plan does not have to pre-approve deep gum and root cleaning (D4341).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on February 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the drug testing. You say that this service was 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 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the drug testing provided on February 1, 2023, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient care. 
 
You asked the Plan to pre-approve continued inpatient care. You say that you disagree with the Plans denial. 
The Plan denied your request. The Plan says the services are 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 pre-approve continued inpatient care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on December 02, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you say that wound care supplies are a 
separately billable expense that does not requeire authorization or referral. The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on December 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray and specialist office visit 
provided on January 17, 2023, and January 19, 2023. 
 
You asked the Plan to waive the copayments for the x-ray and specialist office visit. You say that you were 
given an incorrect diagnosis and feel the services are not worth what you are being charged. 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 an $80 
copayment for x-ray services. Your contract with the Plan also clearly says that you must pay a $35 copayment for each specialist office visit. 
 
You have been asked to pay $76.01, which is less than the standard $80 copayment for the x-ray provided on 
January 17, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit 
category. You have also been asked to pay a $35 copayment for the specialist office visit provided on January 
19, 2023. This item/service falls within the physician/practitioner services benefit category. You have been 
asked to pay a total of $111.01 ($76.01 copayment + $35 copayment = $111.01). 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 copayments for the x-ray and specialist office visit provided on January 17, 2023, and January 19, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. Plan denied your request. The Plan says short tern rehabilitation 
will not improve your current condition. Services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care for the surgical services. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found this enrollee is having colonoscopy with esophagogastroduodenoscopy (EGD) 
procedures. They can safely per performed with a 24 to 48 hour observational stay. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care for the surgical services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 95870 provided to the enrollee on August 18, 2022.
You asked the Plan to pay for procedure code 95870. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says that the payment for code 95870 is included in the payment for code 95861. Although this code pair was billed with a modifier for separate payment, the medical records do not support that this modifier was used appropriately.
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 95870 is a column II code to column I code 95870; however, 95870 was 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 code 95870. Our reviewer says that this service is not supported as separately identifiable. Our reviewer found that the needle electromyography services performed were included in procedure 95861. The use of the 59 modifier is not appropriate in this case. 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 code 95870 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95870 provided to the enrollee on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87591, 87661, 87563) provided to the enrollee on June 7, 2021.
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says that no medical records were received to support the billing of codes 87591, 87661 and 87563.
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 laboratory services have been met. Specifically, no medical records were provided to support that these services were necessary and were reported/billed accurately. Therefore, we decided that the Plan does not have to pay for the laboratory services (87591, 87661, 87563) provided to the enrollee on June 7, 2021.