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

 
We decided that the Plan does not have to pay for Fungal Infection Polymerase Chain Reaction (PCR) Panel 
(87481, 87500, 87641, 87651, 87653, and 87798) provided May 3, 2023. 
 
You asked the Plan to pay for the services. You say that the provided Fungal Infection PCR Panel was 
medically necessary. The Plan denied your request. The Plan says the provided Fungal Infection PCR Panel 
was 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current standard of care for investigation of onychomycosis in a toenail is to perform a KOH 
and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific. It is unclear as to 
why this patient's right hallux nail specimen collected on May 3, 2023, required PCR testing when other less 
expensive and efficacious lab tests (KOH and fungal culture) are available. Therefore, the requested PCR 
testing of this enrollee's right hallux toenail was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Fungal Infection Polymerase Chain Reaction (PCR) Panel (87481, 87500, 87641, 87651, 
87653, and 87798) provided May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided on July 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this represents an unbundled 
code submitted for a panel test. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87798) provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist follow up provided 
on July 20, 2023. 
 
You asked the Plan to waive the copayment for an in-network specialist follow up. You say that this was 
supposed to be a follow up for a biopsy procedure, which should not have a 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an in-network specialist follow up. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 in-network specialist follow up provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 22, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are appealing the claim payment denial. 
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 chiropractic services 
provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 12, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee had two trips on this date of 
service.  You said that one of them was paid and the other was not. The Plan denied your request. The Plan 
says the enrollee had two trips on this date of service.  Based on how the enrollee's contract reads, only one 
$300 copayment was applied to the two trips. 
 
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 $300 copayment per date of service regardless of the number of trips for ambulance services.   
In this case, the enrollee had two separate ambulance trips on this date of service.  Because of how the wording 
of the enrollees contract, only 1 $300 copayment applies for ambulance services, regardless of the number of 
trips on a single date of service.  One of the trips was paid because the $300 copayment was assessed against 
the second trip. The total allowed amount for the second trip is less than the enrollees $300 copayment, so no 
additional payment is due from the Plan. Therefore, we decided that the Plan does not have to pay for 
ambulance services provided on July 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on February 20, 2023, to 
February 21, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that the services were medically necessary. 
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 the inpatient hospital 
stay provided on February 20, 2023, to February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on August 22, 
2023. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you were under the 
impression that this service would be fully covered. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for a breast ultrasound. This item/service 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 a breast ultrasound provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve neurophysiological monitoring (G0453) provided on May 31, 
2023. 
 
You asked the Plan to pre-approve the service. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the services at issue are not medically necessary. 
 
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 service. Our physician reviewer 
found the enrollee appears to have undergone a lumbar spine procedure. The IONM interpretation report 
indicates placement of 6 pedicle screws. Per the LCD, IONM is covered for procedures in which there is: 
"Spinal instrumentation requiring pedicle screws or distraction".  In as much it would appear that criteria for 
coverage of said service would be met, given the placement of instrumentation.  
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 service have been met. Therefore, we decided that the Plan has to pre-
approve neurophysiological monitoring (G0453) provided on May 31, 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 waive the copayment for lab testing provided on June 21, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you want to appeal the amount 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 a $5 
copayment for outpatient hospital services. 
 
You have been asked to pay a $5 copayment for lab testing. This item/service falls within the outpatient 
hospital 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 lab testing provided 
on June 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient hospital care provided 
from July 2, 2023, through July 10, 2023. 
 
You asked the Plan to waive the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. 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 $225 
copayment per day, for days 1-7 for Medicare-covered admissions.  
 
 
  
 
 
 
 
You have been asked to pay $1,575 ($225 copayment x 7 days) for the acute inpatient hospital care provided. 
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 the acute inpatient hospital care provided from July 2, 2023, 
through July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral appliance (E0486) for treatment of obstructive sleep apnea. 
 
You asked the Plan to pre-approve the oral appliance. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
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 oral appliance. Our physician 
reviewer found there is documentation that the oral appliance at issue in this case meets all Medicare criteria 
for medically reasonable and necessary for the patient as summarized in the LCD: Oral Appliances for 
Obstructive Sleep Apnea (L33611). Provided records in this case document an in-person clinical evaluation on 
February 14, 2023, by a treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep 
apnea testing. Records document the enrollee had a Medicare-covered sleep test on March 1, 2023, that showed 
an apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) that was greater than or equal to 5 and 
less than or equal to 14 events per hour (13.1) with a minimum of 10 events (119) and documentation of 
excessive daytime sleepiness and a diagnosis of hypertension. Records indicate the device is ordered by the 
treating practitioner following a review of the report of the sleep test. The device is provided and billed for by a 
licensed dentist (all Doctor of Medicine in Dentistry (DMD's). Records support that requirements for coverage 
as defined by the LCD have been met.  
 
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 oral appliance have been met. Therefore, we decided that the Plan has to 
pre-approve an oral appliance (E0486) for treatment of obstructive sleep apnea.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), polycarbonate lenses 
(V2784), ultraviolet (UV) lenses (V2755), and miscellaneous vision items or services (V2799), and 
photochromatic tint (V2744) provided on July 13, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), polycarbonate lenses (V2784), ultraviolet (UV) 
lenses (V2755), and miscellaneous vision items or services (V2799), and photochromatic tint (V2744). You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says this benefit was 
exhausted for the frames. You are responsible for the overage of the frame. The Plan also says that anti-
reflective coating (V2750), polycarbonate lenses (V2784), ultraviolet (UV) lenses (V2755), and miscellaneous 
vision items or services (V2799), and photochromatic tint (V2744) are excluded from this benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services one pair of eyeglass frames (up to a regular retail value of $140) and 
one pair of standard prescription lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say you pay a $0 copayment for eyeglass frames 
(priced up to a regular retail value of $140) every 24 months when you use a network provider. The Plan rules 
also say you pay $0 for one pair of prescription eyeglass lenses (including single, lined bifocal, lined trifocal, 
and lenticular lenses). Lens enhancements are not covered under this benefit. Based on this information, we 
decided that the Plan's rules for coverage of anti-reflective coating (V2750), polycarbonate lenses (V2784), 
ultraviolet (UV) lenses (V2755), and miscellaneous vision items or services (V2799), and photochromatic tint 
(V2744) have not been met. Therefore, we decided that the Plan does not have to pay for anti-reflective coating 
(V2750), polycarbonate lenses (V2784), ultraviolet (UV) lenses (V2755), and miscellaneous vision items or 
services (V2799), and photochromatic tint (V2744) provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory services 
provided on July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each ultrasound provided on July 25, 2023. 
 
You asked the Plan to reduce the copayment for each ultrasound. You say that you should not have to pay for 
both ultrasounds. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for each ultrasound. This item/service 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. The total amount you owe is $30 ($15 copayment x 2 ultrasounds = $30). Therefore, we decided that the Plan does not have to reduce the copayment for each ultrasound 
provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that the doctor was not responsible to obtain 
authorization. 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 an office visit provided 
on June 09, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service July 18, 2023. 
 
You asked the Plan to pay for code 99284. You say that this claim was underpaid. The Plan denied your 
request. The Plan says code 99284 is not supported by the medical record. The medical record supports the 
level of code 99283 instead. 
 
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 is not supported by the medical records. Our reviewer found the enrollee is a 68-year-old male who was presented to 
the emergency room with headache. Documentation from this date described the enrollee as having an abscess 
of the left ear, conjunctivitis, and hypertension, treated with incision and drainage and oral antibiotics without 
complication. His vitals were stable. The history and exam were each an expanded focus and not detailed. 
Therefore, the code, 99284 is not sufficiently supported and 99283 is better supported for this encounter.  
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service July 18, 2023.