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

 
We decided that the Plan does not have to waive the copayment for fundus photography provided on May 15, 
2023. 
 
You asked the Plan to waive the copayment for fundus photography. You say that you have never had an extra 
copayment before. 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 diagnostic procedures/tests. 
 
You have been asked to pay a $50 copayment for fundus photography. This item/service falls within the 
diagnostic procedures/tests 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 fundus 
photography provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service January 25, 
2023.  
 
You asked the Plan to pay for procedure code 81455. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81455 is bundled into payment for code 81456. 
 
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 81455 is a column II code to column I code 81456 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81455 billed for date of service January 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on October 
07, 2022. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that this was only a short ride, 
and the amount the Plan paid should be enough. 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 $150 
copayment for out-of-network ambulance services. 
 
You have been asked to pay a $150 copayment for the ambulance service. This item/service falls within the 
out-of-network 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 ambulance service provided on October 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous stabilization devices. 
 
You asked the Plan to pre-approve interspinous stabilization devices. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the clinical as scientific 
evidence is insufficient to determine that use of interspinous stabilization devices results in improvement in the 
health outcomes. 
 
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 interspinous stabilization devices. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found interspinous process devices are experimental in spine surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interspinous stabilization devices have not been met. Therefore, we decided that 
the Plan does not have to pre-approve interspinous stabilization devices.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for March 29, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes that 
exclude each other. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed 
for March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9967 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code Q9967. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed code is excluded.  

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 Q9967 has a Status Indicator of E on the Physician Fee Schedule. This means that 
procedure code Q9967 is excluded. Based on this information, we decided that Medicare rules for coverage of 
procedure code Q9967 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code Q9967 billed for date of service May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 21, 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 January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that you thought authorization had been obtained. 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 office visit provided 
on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 17, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral image (D0220) and panoramic imaging (D0330) 
provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like these services should be covered. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0330 was exhausted on date of service March 3, 2020, and D0220 was exhausted with the approved and paid D0230 provided on May 2, 2023. Therefore, we decided that the Plan does not have to 
pay for an intraoral image (D0220) and panoramic imaging (D0330) provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit on December 16, 2022.  
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you were not aware that this 
was going to be charged as a virtual visit and had a follow up question from a previous visit. 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 urgently needed service received via telehealth. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
 
 You have been asked to pay a $50 copayment for telehealth visit. 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 the telehealth visit on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
May 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
urine polymerase chain reaction (PCR) panel rendered on May 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005, defined as electrocardiogram, routine with at 
least 12 leads; tracing only, without interpretation and report, and code 93041, defined as rhythm 
electrocardiogram, 1-3 leads; tracing only without interpretation and report, performed on March 30, 2023. 
 
You asked the Plan to pay for 93005 and 93041. You say that 93005 and 93041 should be paid as billed 
because they were medically necessary. The Plan denied your request. The Plan says 93005 and 93041 are 
denied because they have a status indicator of Q1, indicating each code is an STV-packaged code. Both were 
billed on the same claim as 99285, which has a status indicator of V. 
 The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are assigned a status 
indicator of Q1. STV-packaged services are not eligible for separate payment when a service with status 
indicator S, T, or V is reported on the same claim. 
 
We looked at the file and Medicare rules. We confirmed that 93005 and 93041 have a status indicator of Q1, so 
they are considered STV-packaged services. We confirmed 99285 has a status indicator of V and was billed on 
the same claim with the same date of service, March 30, 2023. Therefore, no separate payment is warranted for 
93005 and 93041. Based on this information, we decided that Medicare rules for coverage of 93005 and 93041 
have not been met. Therefore, we decided that the Plan does not have to pay for code 93005, defined as 
electrocardiogram, routine with at least 12 leads; tracing only, without interpretation and report, and code 
93041, defined as rhythm electrocardiogram, 1-3 leads; tracing only without interpretation and report, 
performed on March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires close daily oversight of care by a physician in an inpatient setting. The Plan denied your request. The Plan says the coverage criteria is not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy in an intensive rehabilitation program. Medically necessary care can be provided in a different level of care. There is no reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services (G0299 x5) and home health 
physical therapy services (G0151 x4). 
 
You asked the Plan to pre-approve home health services. You say that the enrollee requires the additional 
physical therapy sessions requested due to muscle weakness and deconditioning. The Plan denied your request. 
The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires skilled therapy, with services requiring the skills of a 
qualified therapist. The request for ongoing skilled therapy is not reasonable and necessary for the treatment of 
the enrollee's illness or injury. The enrollee is at a high functional level that no longer requires ongoing formal 
therapy. The request for home health services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing services (G0299 x5) and home health physical therapy services 
(G0151 x4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87086, 87186, 87481, 87500, 87556, 87563, 
87640, 87651, 87653, 87798, and 87077 billed for November 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, 
87798, and 87077 are not supported. 
 
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 87086 is culture, bacterial; quantitative colony count, 
urine. The definition of code 87186 is susceptibility studies, antimicrobial agent; microdilution or agar dilution 
(minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate. The definition of 
code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); 
vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. The definition of 
code 87556 is infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified 
probe technique. The definition of code 87563 is infectious agent detection by nucleic acid (DNA or RNA); 
Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection 
by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The definition of code 
87651 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe 
technique. The definition of code 87653 is infectious agent detection by nucleic acid (DNA or RNA); 
Streptococcus, group B, amplified probe technique. The definition of code 87798 is infectious agent detection 
by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The 
definition of code 87077 is culture, bacterial; aerobic isolate, additional methods required for definitive 
identification, each isolate. 
 
We find that CPT codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, 87798, and 87077 
are not supported in the medical record. Specifically, there are no results for any of the listed codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87086, 87186, 87481, 87500, 87556, 87563, 
87640, 87651, 87653, 87798, and 87077 billed for November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0092 billed for May 18, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code Q0092 is not supported. 
 
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 Q0092 is set-up portable x-ray equipment. 
 
We find that CPT code Q0092 is not supported in the medical record. Specifically, there is no documentation 
of transportation of portable x-ray equipment and personnel to home or a nursing home. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code Q0092 billed for May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that you didnt receive authorization until 
after the visit had concluded. 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 April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urinary Tract Infection panel provided on June 1, 2023, 
and billed with codes 87481, 87500, 87640, 87652, and 87798. 
 
You asked the Plan to pay for the Urinary Tract Infection panel. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Urinary Tract Infection panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the Urinary Tract Infection panel 
provided on June 1, 2023, and billed with codes 87481, 87500, 87640, 87652, and 87798.