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

 
We decided that the Plan does not have to waive the copayment for the diagnostic test (92134) provided on 
June 28, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic test (92134). You say that you should not be 
responsible for this charge. 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 servicesand supplies. 
 
You have been asked to pay a $15 copayment for the diagnostic test (92134). This item/service falls within the 
Outpatient diagnostic tests and therapeutic servicesand 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 the diagnostic test (92134) provided on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date of service 
May 22, 2023.  
 
You asked the Plan to pay for procedure codes 87634 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87634 is 1. The MUE for CPT code 87798 is 13. The MAI value for these 
codes is 3. You billed 2 units of code 87634 and 14 units of 87798, exceeding the MUE. You did not provide 
all the required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
87634 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 87634 and 87798 billed for date of service May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided 
on August 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliances provided on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies (A4358, A6402, 
A6258) provided on April 11, 2023, to May 10, 2023. 
 
You asked the Plan to waive the coinsurance for the wound care supplies (A4358, A6402, A6258). You say 
that the cost share is wrong. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the wound care supplies (A4358, A6402, A6258). This 
item/service falls within the durable medical equipment (DME) and related 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 coinsurance for the wound care supplies (A4358, A6402, A6258) provided 
on April 11, 2023, to May 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) 
provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy (45378). You say that the cost share 
is wrong. 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 $275 
copayment for outpatient surgery. 
 
You have been asked to pay a $275 copayment for the diagnostic colonoscopy (45378). This item/service falls 
within the outpatient surgery 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 the 
diagnostic colonoscopy (45378) provided on July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not need ventilator weaning and does not have complex wound care 
needs. The enrollee does not meet an LTACH admission criteria. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket for a lower limb prosthesis (L5781). 
 
You asked the Plan to pre-approve the vacuum socket for a lower limb prosthesis. You say that this item is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 vacuum socket for a lower limb 
prosthesis. Our reviewer says that this feature is not medically necessary. Our physician reviewer found this 
device has not been shown to improve function significantly over standard sockets. The device is not medically 
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 vacuum socket for a lower limb prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a vacuum socket for a lower limb prosthesis (L5781).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the total knee arthroplasty provided on May 
09, 2022, to May 10, 2022. 
 
You asked the Plan to waive the copayment for the total knee arthroplasty. You say that you are not paying the 
$118.50 after all this time. 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 $295 
copayment for outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters. 
 
You have been asked to pay a $295 copayment for the total knee arthroplasty. This item/service falls within the outpatient surgery, including services provided athospital outpatient facilities and ambulatory surgicalcenters 
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. 
However, since the allowed amount is less than the standard copayment, you only owe $118.50. Therefore, we 
decided that the Plan does not have to waive the copayment for the total knee arthroplasty provided on May 09, 
2022, to May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 20, 
2023, to June 23, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $295 
copayment for inpatient hospital care. 
 
You have been asked to pay a $295 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital 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. The total amount you owe is $885 ($295 x 3 days = $885). Therefore, we decided that the 
Plan does not have to waive the copayment for inpatient hospital care provided on June 20, 2023, to June 23, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the out-of-network ambulance service 
provided on June 27, 2023. 
 
You asked the Plan to waive the copayment for the out-of-network ambulance service. You say that the cost 
share is wrong. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the out-of-network ambulance service. This item/service 
falls within the ambulance 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 
the out-of-network ambulance service provided on June 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network spinal procedure 
provided on June 08, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network spinal procedure. You say that you were not 
advised that this provider was out-of-network. This bill amount is too large, no one told you this would happen 
and you cannot afford it. 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 40% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay 40% coinsurance for an out-of-network spinal procedure. This item/service falls 
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. The total you owe is $6,639.23 ($16,598.08 x 40% = $6,639.23). Therefore, we decided 
that the Plan does not have to waive the coinsurance for an out-of-network spinal procedure provided on June 
08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85007 and 85027 billed for date of service 
July 6, 2023.  
 
You asked the Plan to pay for procedure codes 85007 and 85027. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 85007 and 85027 is bundled into 
payment for code 85025. 
 
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 85007 
is a column two code to column one code 85025 with a modifier indicator of 0. The column two code is 
therefore not payable. In this case, we have confirmed that code 85027 is a column II code to column I code 
85025. 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 procedure codes 85007 and 85027 billed for date of service July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for follow-up inpatient consultation provided on August 09, 
2023. 
 
You asked the Plan to pay for follow-up inpatient consultation. You say that the services should be covered. 
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 follow-up inpatient 
consultation provided on August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99233) 
provided July 10, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the diagnosis codes should not be reported together which is based on the Excludes1 Notes 
instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The billed services: 99233 was 
denied because the diagnosis codes associated to F30.9 and F31.9, should not be reported together. The 
primary DX code listed on all claims 30.9 Manic episode, unspecified has an Excludes1 Note for Bipolar 
disorder (F31.-). Further research shows that DX code F31.9 is Bipolar disorder, unspecified - Manic 
depression. Therefore, the claim is an uphold as following the CMS's ICD-10-CM Exclude1 Note Guidelines. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital inpatient or observation 
care (99233) provided July 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on August 09, 2023. 
 
You asked the Plan to pay for diagnostic imaging. You say that a prior authorization was not required for this 
code. 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 diagnostic imaging 
provided on August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy service provided on 
August 02, 2023, to August 28, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy service. You say that you disagree with 
the copayments. 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 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy service. This item/service falls within 
the outpatient rehabilitation 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. The total amount you owe is $100 ($20 copayment x 5 visits = $100). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy service 
provided on August 02, 2023, to August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography services (95861, 95870) provided 
on August 2, 2023. 
 
You asked the Plan to pay for needle electromyography services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the services at issue are not a 
covered benefit in the enrollee's clinical situation. 
 
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 needle electromyography services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee underwent EMG in the setting of intraoperative monitoring. 
EMG in this context was not used for diagnostic purposes or for an indication supported within the rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography services have not been met. Therefore, we decided 
that the Plan does not have to pay for needle electromyography services (95861, 95870) provided on August 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted procedure, nervous system (64999) provided June 
19, 2023. 
 
You asked the Plan to pay for the procedure. You say that please see requested medical records and reprocess 
claim for payment. The Plan denied your request. The Plan says under Medicare guidelines, this is not a 
covered benefit because the records show the requested service is integral to another, approved service, and is 
not able to be unbundled. 
 
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 64999 is a column II code to column I code 01810; however, 64999 
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 the procedure. Our reviewer says that the billed service is not 
supported in the record in this case. Our reviewer found the record does not show that a separately identifiable 
unlisted procedure was performed on the nervous system. The procedures performed are included in the 
approved anesthesia codes. The record does not support that 64999 is a separately reportable procedure 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pay for unlisted procedure, nervous system (64999) provided June 19, 2023.