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

 
We decided that the Plan does not have to pay for procedure codes 93010, 99152, and 99153 rendered on 
December 12, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed services were 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 the denied codes is: 
 
CPT 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
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 services. Our reviewer says that that CPT 93010 and 
99152 were not supported by the medical records. Our reviewer found that there was no documentation of the 
billed 12 lead ECG (CPT 93010) during the procedure. Likewise, the two units of billed conscious sedation 
specifically require description of monitoring by qualified medical personnel to be documented. This was 
implied but not specifically documented in the records. Absent such documentation, these codes are not 
supported. 
 
Medicare rules also say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93010, 99152, and 99153 rendered on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on May 23, 2023. 
 
You asked the Plan to pay for D2950. You say that you believe that this should be covered. The Plan denied 
your request. The Plan says D2950 is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided on May 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tafluprost. 
 
You asked the Plan to pre-approve the medication. You say that Tafluprost is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tafluprost.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal polymerase chain reaction (PCR) panel provided on 
January 12, 2023.  
 
You asked the Plan to pay for a fungal PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is considered experimental or investigational.  
 
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 a fungal PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records document the PCR panel was chosen as opposed to a standard fungal 
culture and histopathology as the PCR panel can shorten the time to definitive diagnosis by up to 4 to 5 days. 
Given that the records also report that the enrollee's condition had been present for more than 10 years, it is not 
clear that a definitive diagnosis by up to 4 to 5 days sooner was medically necessary for the enrollee in this 
case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a fungal PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for a fungal polymerase chain reaction (PCR) panel provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 rendered on September 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records submitted do not support a comprehensive history. 
 
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 99223 is "initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report only 
describes a detailed history, not comprehensive. In this case, there is a more appropriate code to report. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 rendered on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 26, 2023, to May 10, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on April 26, 2023, to May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 13, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment provided on January 06, 
2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that the medical equipment company 
said your Plan would reimburse you this amount. 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 cervical traction 
equipment provided on January 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liver biopsy provided on December 20, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the liver biopsy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to non-Medicare covered dental services covered by the Plan. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the liver biopsy provided on December 20, 2022, 
by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
April 17, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not go to the 
emergency room on this date. 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 $110 
copayment for in-network and out-of-network emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room visit. This item/service falls within the 
in-network and out-of-network emergency 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 records show you were seen in the emergency room on April 
17, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
visit provided on April 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine heart study provided 
on March 27, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine heart study. You say that the procedure 
was not completed due to health issues. 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 $60 
copayment for in-network outpatient x-rays and ultrasounds.  
 
The records confirm that the procedure was not completed, and the Plan only applied one-half of the 
copayment. You have been asked to pay a $30, which is half of the standard $60 copayment for the nuclear 
medicine heart study. This item/service falls within the outpatient diagnostic tests and therapeutic 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 nuclear medicine heart study 
provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesiology services billed with code 00811 for March 8, 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 that the claim was not billed with a CPT code or description of the service. 
 
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. The Plan states that the claim was not billed with a CPT code or description of 
service; however, the file does not contain a claim form showing that the services were not billed with code 
00811. The Plan has not provided any documentation to support that the claim is not payable as billed. 
Therefore, we decided that the Plan has to pay for the anesthesiology services billed with code 00811 for 
March 8, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on March 
03, 2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you should not have to pay 
for this service. 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 in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an electrocardiogram. This item/service falls within the in-
network 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 an electrocardiogram provided on March 03, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on May 6, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that the 
doctor didn't even touch your broken arm or change the splint.  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 $90 
copayment for emergency services.  
 
You have been asked to pay the allowed amount of $74.08 which is less than the $90 copayment for an in-
network emergency room (ER) visit. This item/service falls within the emergency 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 an in-network emergency room (ER) visit provided on May 
6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 18, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a Prolia injection provided on April 26, 
2023. 
 
You asked the Plan to reduce the coinsurance for a Prolia injection. You say that you cannot afford the 
coinsurance. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a Prolia injection. This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $320.41 ($1,602.05 allowed amount x 20% = $320.41). Therefore, 
we decided that the Plan does not have to reduce the coinsurance for a Prolia injection provided on April 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cognitive function therapeutic intervention services provided 
on March 09, 2023. 
 
You asked the Plan to pay for cognitive function therapeutic intervention services. You say that the provider 
was not responsible for obtaining 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 cognitive function 
therapeutic intervention services provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 13, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say that the member is in an 
approved nursing facility and that the charges 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 home visit for 
evaluation provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on March 9, 
2023. 
 
You asked the Plan to pay for the CxBladder Detect testing (0012M). 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. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered as billed. Therefore, we decided 
that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on March 9, 2023.