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

 
We decided that the Plan does not have to waive the cost share for hospital observation on March 21, 2023.  
 
You asked the Plan to waive the cost share for hospital observation. You say that you want to appeal the 
amount being charged. 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 must 
pay a 10% coinsurance of the approved amount after deductible for hospital observation. Covered services 
include but are not limited to services in an emergency department or outpatient clinic, such as observation 
services or outpatient surgery. There is a $150 deductible and a $9 coinsurance. $150 + $9 = $159. Therefore, 
results in the total cost sharing amount of $159. 
 
You have been asked to pay a $159 cost share for hospital observation. This item/service falls within the 
outpatient hospital 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 cost share for hospital 
observation on March 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 11, 2023, to March 15, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not told about 
this coinsurance and cannot afford to pay it. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $320 
copayment per day for days 1-6 of each in-network inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment for any additional days of the same in-network inpatient hospital 
stay. 
 
You have been asked to pay a $320 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
four or for the day you were discharged. You have been asked to pay a total of $1,280 for the inpatient hospital 
stay ($320 copayment per day x 4 days = $1,280). 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 inpatient hospital stay provided from March 11, 2023, to March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray provided on May 10, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the abdominal x-ray. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was 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 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 abdominal x-ray provided on May 10, 2023, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for spine x-rays provided on April 26, 2023. 
 
You asked the Plan to waive the copayment for spine x-rays. You say that these services should be included in 
the specialist 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 $15 
copayment for each Medicare-covered standard x-ray service. 
 
You have been asked to pay a $15 copayment for spine x-rays. This item/service falls within the each 
Medicare-covered standard x-ray service 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 spine x-rays provided on April 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network endoscopy procedure 
provided on May 10, 2023. 
 
You asked the Plan to reduce the copayment for an in-network endoscopy procedure. You say that you were 
expecting a $200 copayment, not this $350 bill. Please lower the amount. 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 outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for an in-network endoscopy procedure. This item/service falls 
within the outpatient hospital facility 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 reduce the copayment for 
an in-network endoscopy procedure provided on May 10, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 25028. We decided that the Plan does not have to pay 
for procedure code 25290.  
 
You asked the Plan to pay for procedure codes 25028 and 25290 provided on December 24, 2022.. You say 
that you would like the Plan to reconsider their denial of payment. The Plan says that the services are not 
covered as billed. 
 
We decided that the Plan has to pay for procedure code 25028.  
 
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 25028 
is not a column II code to code 25609. Based on the claim submitted, Medicare billing criteria have been met. 
Therefore, we decided that the Plan has to pay for procedure code 25028.  
 
We also decided that the Plan does not have to pay for procedure code 25290. 
 
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 25290 is a column II code to column I code 25260; however, 25290 
was billed with a modifier. 
 
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 procedure code 25290. Our reviewer says 
that the medical records do not support the use of modifier XU with procedure code 25290. Our physician 
reviewer found the description of the procedure cites the flexor carpi radialis (FCR) tendon sheath was released 
both superficial and deep. The FCR tendon was retracted radially to assist in protecting the radial artery. The 
flexor space was then entered and developed bluntly, and a self-retaining retractor was placed.  
 
The procedure indicates the FCR tendon was retracted to assist in the protection of the radial artery for the 
following procedure. Therefore, the documentation does not support that CPT 25290: tenotomy, open, flexor or 
extensor tendon, forearm and/or wrist, single, each tendon was distinct from CPT 25260.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 25290 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 25290. 
 
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 x-ray provided on April 13, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you want to appeal the amount being 
charged. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for an x-ray. 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 an x-ray provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye examination provided on March 09, 
2023. 
 
You asked the Plan to waive the copayment for the eye examination. You say that this should be considered 
routine vision exam. 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 $35 
copayment for in-network vision care. 
 
You have been asked to pay a $35 copayment for the eye examination. This item/service falls within the in-
network vision 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 medical records show this was a diagnostic evaluation. Therefore, we decided that the Plan 
does not have to waive the copayment for the eye examination provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injections provided on November 28, 2022. 
 
You asked the Plan to pay for the therapeutic injections. You say that you are appealing the denial with 
supporting documentation. 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 therapeutic 
injections provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Breast Cancer Index testing (81518) provided on March 10, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this claim was submitted with an inappropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have not been met. Specifically, the primary diagnosis code reported on this claim was Z17.0 (estrogen receptor positive status [ER+]). However, Z17 codes have a "Code First" 
note directing providers to report malignant neoplasm of breast (C50.-) before a Z17 code. Therefore, we 
decided that the Plan does not have to pay for Breast Cancer Index testing (81518) provided on March 10, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 87798 
billed for date of service February 10, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these services are not supported for separate payment. 
 
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 87150, 87481, 87641, 87653 and 87798 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 were each billed with a 
modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. 
Our reviewer says that these codes are not supported for separate reporting or payment. Our reviewer found the 
use of the XU modifier is not supported with these codes, as the records do not show that they were performed 
in addition to and distinct from the primary procedures. 
 
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 codes 87150, 87481, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 
87798 billed for date of service February 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-rays provided on April 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the x-rays. You say that this is supported in the records. 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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 chest x-rays provided on April 4, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an office visit provided on May 9, 2023. 
 
You asked the Plan to reduce the cost share for an office visit. You say that the allowed amount for this service 
has changed. 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 $800 deductible which applies to doctor and other health care 
provider services. Your contract with the Plan also clearly says that you must pay 10% of the approved amount 
for the office visit. 
 You have been asked to pay $18.70, which is 10% coinsurance of the allowed amount for the office visit $187 
allowed amount x 10% = $18.70). The remaining allowed amount is $168.30. This item/service falls within the 
doctor and other health care provider services 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. 
 
You have been asked to pay $168.30 towards your deductible for the office visit. The item or service you asked 
the Plan to reduce the cost share for falls within the doctor and other health care provider services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to doctor and other health care provider services. This cost sharing is a contractual 
obligation that had not been met at the time an office visit was received on May 9, 2023. Therefore, we decided 
that the Plan does not have to reduce the cost share for an office visit provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 05, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 service 
provided on May 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee has significant spinal canal stenosis which may be the 
cause of pain and there is no documentation for evaluation and treatment of osteoporosis. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered if certain 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is no documentation of trial 
and failure of a back brace for fracture treatment. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T12 kyphoplasty surgery.
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 June 15, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine heart study. You say that you were told 
there would be no cost for this test. 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 outpatient diagnostic radiology.  
 
You have been asked to pay a $350 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic radiology 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 June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 10, 2023. 
 
You asked the Plan to pay for the home visit. You say that the service was 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 home visit provided 
on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on March 03, 2023. 
 
You asked the Plan to pay for the anesthesia 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 anesthesia services 
provided on March 03, 2023.