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

 
We decided that the Plan does not have to waive the copayment for Computed tomography (CT), head or brain 
provided on March 03, 2023. 
 
You asked the Plan to waive the copayment for Computed tomography (CT), head or brain. You say that you 
say you cannot afford to pay the billed amount because you are on a fixed income. 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 $200 
copayment for advanced imaging. 
 
You have been asked to pay a $200 copayment for Computed tomography (CT), head or brain. This 
item/service falls within the advanced imaging 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 $103.36. Therefore, we decided that the Plan does not have to waive the copayment 
for Computed tomography (CT), head or brain provided on March 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the biopsy procedure provided on January 
12, 2023. 
 
You asked the Plan to reduce the copayment for the biopsy procedure. You say that this is a diagnostic 
procedure, and should have a 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 $350 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $350 copayment for the biopsy procedure. This item/service falls within the in-
network 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. According to Medicare the biopsy procedure (code 10005) is considered a surgical 
procedure. Therefore, we decided that the Plan does not have to reduce the copayment for the biopsy procedure 
provided on January 12, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 29880 provided on November 23, 2022. 
 
You asked the Plan to pay for procedure code 29880. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that procedure code 29880 is bundled into 
payment for procedure code 29879. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan is denying payment for Current Procedural Terminology 
(CPT) code 29880 as being bundled into payment for CPT code 29879. The Plan has not provided any 
Medicare documentation confirming that CPT codes 29880 and 29879 cannot be separately paid for. There are 
no National Correct Coding Initiative (NCCI) edits for these codes billed together. Therefore, we decided that 
the Plan has to pay for procedure code 29880 provided on November 23, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on 
February 6, 2023. 
 
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 78815 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 February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on January 17, 2023. 
 
You asked the Plan to pay for a home or residence visit. You say that it is the responsibility of the facility 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 a home or residence visit 
provided on January 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing care provided on October 
28, 2022, to December 12, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing care. You say that you were told this was a 
100% covered stay. 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 skilled nursing facility (SNF) care. 
 
You have been asked to pay a $100 copayment for skilled nursing care. This item/service falls within the 
skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $2,400 ($100 COST SHARE x 44/days = $2,400) 
Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing care provided on 
October 28, 2022, to December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered 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 an office visit provided 
on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on January 31, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that it is not possible to request 
authorization before the services are rendered. 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 principal care 
management services provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on March 08, 2023. 
 
You asked the Plan to pay for surgical pathology services. You say that this was medically necessary and 
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 surgical pathology 
services provided on March 08, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 15, 2022, 
through November 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you want the Plan to pay for the 
services. The Plan denied your request. The Plan says that inpatient level of care was 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 15, 2022, through November 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service October 26, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that this claim should be 
paid due to medical necessity.  The Plan denied your request. The Plan says payment for codes 87481, 87653, 
and 87798 is bundled into payment for code 87801. 
 
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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. Codes 87481 and 87653 have not been 
billed with an appropriate modifier to bypass the edit. While code 87798 was billed with modifier -XU, there is 
no evidence to support that this was a non-overlapping service with the panel described by code 87801. 
 
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 87481, 87653, and 87798 billed for date of service October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on October 31, 2022. 
 
You asked the Plan to pay for wound care services. You say that this service is supported in the records. 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 services 
provided on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 87900. You say that these services were medically necessary and 
were reported with covered codes. The Plan denied your request. The Plan says this code is not supported in the 
medical record. 
 
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 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 87900. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the medical record does not confirm that susceptibility 
with phenotype prediction and regularly updated genotypic bioinformatics was performed. Although 
susceptibility was documented, the method of obtaining it is not specified. It cannot be verified that the 
components of 87900 were performed. 
 
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 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 billed for date of service November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing for thyroglobulin antibody (86800), total 
thyroxine (84436), free thyroxine (84439), thyroid stimulating hormone (TSH) (84443), total triiodothyronine 
T3 (TT-3) (84480), free triiodothyronine T3 (84481) and reverse triiodothyronine T3 (84482) provided on 
August 30, 2022. 
 
You asked the Plan to pay for the testing for thyroglobulin antibody, total thyroxine, free thyroxine, TSH, TT-
3, free triiodothyronine T3 and reverse triiodothyronine T3. You say that this testing should be covered. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the testing for thyroglobulin antibody, total thyroxine, free thyroxine, TSH, TT-
3, free triiodothyronine T3 and reverse triiodothyronine T3, appears to have been requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the testing for thyroglobulin antibody (86800), total thyroxine (84436), free thyroxine 
(84439), thyroid stimulating hormone (TSH) (84443), total triiodothyronine T3 (TT-3) (84480), free 
triiodothyronine T3 (84481) and reverse triiodothyronine T3 (84482) provided on August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the 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 kyphoplasty is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of fracture bracing. 
More conservative measures are needed prior to surgery. The kyphoplasty is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pelvic endoscopy provided on January 03, 2023. 
 
You asked the Plan to pay for a pelvic endoscopy. You say that this was medically necessary and 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 a pelvic endoscopy 
provided on January 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing for candida species provided on December 30, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab testing for candida species. 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 lab testing for candida species provided on December 30, 
2022, by an out-of-network (OON) provider.