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

 
We decided that the Plan does not have to waive the copayment for immunization provided on September 13, 
2023. 
 
You asked the Plan to waive the copayment for immunization. You say that you were not aware this service 
would not be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for immunizations. 
 
You have been asked to pay a $110 copayment for immunization. This item/service falls within the 
immunizations 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 immunization provided on 
September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service July 18, 
2023. 
 You asked the Plan to pay for procedure code 76775. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76775 is bundled into payment for code 76770. 
 
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 76775 
is a column II code to column I code 76770. 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 code 76775 billed for date of service July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on August 18, 
2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you are requesting the deductible 
fee to be waived. 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. Your 
contract with the Plan says that there is a $950 deductible which applies to certain items and services. The Plan 
deductible applies to an out-of-network office visit. The Plan contract also says that enrollees must pay 45% 
coinsurance for an out of-network office visit after the deductible has been met. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $950 deductible which applies to the out-of-network office visit. This 
cost sharing is a contractual obligation that had not been met at the time the out-of-network office visit was 
received on August 18, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
office visit provided on August 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service 
November 1, 2022. 
 
You asked the Plan to pay for the billed service. You say that this was an emergency situation. The Plan denied 
your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The file shows that the enrollee received transportation from one hospital to 
another. The enrollee was an inpatient at the time the services were provided. The ambulance services billed by 
independent suppliers that should be bundled to the hospital where the enrollee was receiving inpatient care. 
Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation billed for date of 
service November 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on March 20, 2023. 
 
You asked the Plan to pay for x-ray services. You say that medical records were 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 x-ray services provided 
on March 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for you disagree with the copayment. provided 
on July 14, 2023. 
 
You asked the Plan to waive the copayment for you disagree with the copayment.. 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 $260 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $260 copayment for you disagree with the copayment.. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for you disagree with the copayment. provided on July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20931, 20937, and 63081 rendered on June 
29, 2023.  
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 there is no documentation of 
autologous bone graft taken from a separate incision. Therefore, CPT 20937 is not appropriate. CPT 63081 is 
included in the CPT 22220 osteotomy code and should not be billed separately. 
 
Additionally, the Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery 
indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for 
Current Procedural Terminology (CPT) code 20931. The Medicare Fee Schedule Database contains a surgical 
indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria 
for CPT 20931 have not been met. 
 
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 20931, 20937, and 63081 rendered on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MI Tumor Seek Hybrid testing (81479) provided on June 
15, 2023. 
 
You asked the Plan to pay for the MI Tumor Seek Hybrid testing (81479). You say that the MI Tumor Seek 
Hybrid testing (81479) provided was medically necessary. The Plan denied your request. The Plan says the 
enrollee did not meet criteria for the MI Tumor Seek Hybrid testing (81479) provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the MI Tumor Seek Hybrid testing (81479). 
Our reviewer says that the enrollee did not meet criteria for the MI Tumor Seek Hybrid testing (81479) 
provided. Our physician reviewer found the enrollee is with a 50-pack year smoking history. A left upper lobe 
lung adenocarcinoma was diagnosed on April 6th, 2023. In this case the enrollee does not have recurrent, 
relapsed, refractory, or metastatic cancer.  And the physician note states this is likely an early stage cancer and 
resectable. So, unless there is a documentation showing post-staging work-up showing advanced cancer, the 
enrolleee does not meet 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 MI Tumor Seek Hybrid testing (81479) have not been met. Therefore, we 
decided that the Plan does not have to pay for the MI Tumor Seek Hybrid testing (81479) provided on June 15, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient mental health visit provided 
on July 31, 2023. 
 
You asked the Plan to waive the copayment for outpatient mental health visit. You say that this was a telehealth 
service and you did not go into the facility. 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 $15 
copayment for outpatient mental health care visit.  
 
You have been asked to pay $15 copayment for outpatient mental health visit. This item/service falls within the 
Outpatient Mental Health 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. Therefore, we decided that the Plan does not have to waive the copayment for 
an outpatient mental health visit provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity revascularization. 
 
You asked the Plan to pre-approve lower extremity revascularization. You say that the enrollee would benefit 
significantly from this service due to persistent symptoms despite conservative therapy. The Plan denied your 
request. The Plan says that a review of the current medical literature has determined that the requested service 
is not medically necessary for the enrollee's clinical condition. 
 
The Plan follows Medicare rules. Medicare rules say that PTA may be covered under certain circumstances. 
 
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 lower extremity revascularization. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that as described in 
NCD 20.7, angiography, angioplasty, and stent placement are covered by Medicare for treatment of 
atherosclerotic obstructive lesions in the lower extremities, i.e., the iliac, femoral, and popliteal arteries. 
Provided records in this case document evidence of tibial artery atherosclerotic obstructive disease but there is 
no evidence of iliac and/or femoral artery atherosclerotic obstructive disease on the testing provided to support 
necessity of the denied procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lower extremity revascularization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 80053 and 85025 on 
September 30, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 26, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services billed with codes 80053 and 85025 on 
September 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF stay from April 17, 2023, to April 30, 2023. 
 
You asked the Plan to pay for the SNF stay. You say that the provider was not billing the dates of service 
correctly, so you do not think the billed amount is correct. The Plan denied your request. The Plan says the 
enrollee has exhausted the 100-day benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 20, 
2022, to April 16, 2023. The Plan has covered 100 days of SNF care.  
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the SNF stay from April 17, 2023, to April 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0483 and 80307 billed for February 28, 
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 codes G0483 and 80307 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 G0483 is definitive drug testing, 22 or more drug classes. 
The definition of code 80307 is drug test(s), presumptive, any number of drug classes, any number of devices 
or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without 
chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the records do 
not include laboratory results to support these codes for the billed date of service. 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 G0483 and 80307 billed for February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that this wheelchair 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 a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says that this wheelchair is not medically necessary. Our physician reviewer found the records do not include a 
home assessment to show that the enrollee can safely operate this equipment in the home. The records show 
that the enrollee can be assisted by a walker, cane, or manual wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 17 additional fractions of IGRT. We decided that the Plan does not 
have to pre-approve 8 additional fractions of IGRT beyond 25 total.  
 
You asked the Plan to pre-approve 25 additional fractions of image-guided radiation therapy (IGRT). You say 
that this is medically necessary to ensure that the breath hold is consistent from day-to-day. The Plan says that 
this is not medically necessary. 
 
We decided that the Plan has to pre-approve 17 additional fractions of IGRT.  
 
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 the item/service at issue. Our reviewer 
says that 17 additional fractions of IGRT are medically necessary. Our physician reviewer found it is plausible 
that IGRT would be of benefit when treating the chest wall. As such, the need for 25 units is within accepted 
standards of care.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve 17 additional fractions of IGRT.  
 
We also decided that the Plan does not have to pre-approve 8 additional fractions of IGRT beyond 25 
total. 
 
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 the item/service at issue. Our reviewer 
says that 8 additional fractions of IGRT are not medically necessary. Our physician reviewer found the letter 
dated December 4, 2023 only requests IGRT for 25 fractions. IGRT is only justified and needed for the chest 
wall treatment (totaling 25 fractions).  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional fractions of IGRT beyond 25 total. 
 
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.