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

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
April 27, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you do not 
understand why this was not covered as a preventive procedure. 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 $250 
copayment for outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This item/service falls within 
the outpatient surgery in an ambulatory surgical center 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 you received a diagnostic 
colonoscopy with polyps removed on April 27, 2023. Therefore, we decided that the Plan does not have to 
waive the copayment for the diagnostic colonoscopy provided on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes G0483 and 80307) 
rendered on May 9, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 unit) and Current 
Procedural Terminology (CPT) code 80307 (1 unit) remains 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: 80307: 
 
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 
 
G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 enrollee was being treated 
with Norco, Gabapentin, Naloxone, and Soma for chronic pain, and was ordered drug testing on 5/9/23 by their 
treating physician. However, the results of such definitive drug testing were not provided in the records to help 
verify the testing was actually performed in this case. Therefore, the documentation does not support this 
request for definitive drug testing of 22+ classes from 5/9/23. 
 
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 laboratory services (procedure codes G0483 and 80307) rendered on May 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
January 25, 2023, to January 30, 2023, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this
should be paid for. The Plan denied your request. The Plan says that reasonable clinical evidence within the
health record must be present to clinically validate the diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with principal
diagnosis code, N17.9 defined as Acute kidney failure, unspecified. Our Medical Director states that the
enrollee had a medical history that included heart disease, stroke, diabetes, hypertension, and chronic kidney
disease. The enrollee was admitted to the hospital with urinary retention with bilateral hydronephrosis and fecal
impaction. A urinary catheter was placed. It was noted that the enrollee had acute-on-chronic kidney disease,
stage IV. The serum creatinine went from 2.39 on January 24, 2023, to 2.0 on January 26, 2023. On January
27, 2023, the enrollee was in no acute distress. The available clinical documentation does not support DRG 683
(Renal failure with complication or comorbidity) with the principal diagnosis code of N17.9 (Acute kidney
failure, unspecified) in this case, based on the serum creatinine values. Our Medical Director found that the
enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from January 25,
2023, to January 30, 2023, at the DRG originally billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from January 25, 2023, to January 30, 2023, at the
Diagnosis Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural injection provided on July 24, 
2023. 
 
You asked the Plan to waive the copayment for the epidural injection. You say that you were not informed 
prior to receiving these services that there would be a copayment of $325. 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 $325 
copayment for in-network outpatient surgery provided in an outpatient hospital. 
 
You have been asked to pay a $325 copayment for the epidural injection. This item/service falls within the in-
network outpatient surgery provided in an outpatient hospital 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 epidural injection provided on July 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp.  
 You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the requested drug is subject to step therapy. 
The preferred drugs the enrollee may not have tried are Retacrit or Procrit.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from, the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
rendered on April 17, 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. 
 
In this case, the CPT Code Manual definition of code 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
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 enrollee was treated in the 
hospital on April 17, 2023. The provided documentation described the enrollee as status post operative day one 
laparoscopic surgery for abscess from recent mesh placement, ventral hernia repair and inguinal hernia repair. 
The enrollee was described as hemodynamically stable, on room air, still NPO (nothing by mouth), awake and 
alert, unremarkable abdominal examination, JP drains with small amount of serosanguinous fluid only, 
tolerating antibiotics, etc. Although the history and examination were appropriate, the documentation does not 
sufficiently support a high level of medical decision-making or duration of the encounter lasting 50+ minutes to 
justify CPT 99233.  
 
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 evaluation and management services (procedure code 99233) rendered on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 4, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says you are not enrolled 
in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injections provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for the injections. You say that you did not understand the $100 
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 $100 
copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical 
centers. 
 
You have been asked to pay a $100 copayment for the injections. This item/service falls within the outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers 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 injections provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87529, and 87640 billed for date of 
service June 15, 2023.  
 
You asked the Plan to pay for procedure codes 87481, 87529, and 87640. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87481 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. The MUE for CPT code 87529 is 2. The MAI value for this code is 3. You billed 3 
units of this code, exceeding the MUE. The MUE for CPT code 87640 is 1. The MAI value for this code is 3. 
You billed 2 units of this code, exceeding the MUE. You did not provide all the required evidence showing that 
the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure code 87481, 87529, and 87640 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87529, and 
87640 billed for date of service June 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 94640 billed for date of service August 17, 2023. 
 
You asked the Plan to pay for code 94640. You say that this is a payable service. The Plan denied your request. 
The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 94640 have not been met. Therefore, we decided that the Plan does not have to pay for code 
94640 billed for date of service August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on August 10, 2023. 
 
You asked the Plan to pay for the office visit (99213). 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 office visit (99213) 
provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on August 
07, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the cost share is wrong 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 $155 
copayment for outpatient surgery. 
 
You have been asked to pay a $155 copayment for the outpatient surgery. This item/service falls within the 
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. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient 
surgery provided on August 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81439 and 81442 
for date of service November 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with codes 81439 and 81442 for date of service November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided April 26, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that you request this 
claim be reconsidered as a medically necessary preventative measure. The Plan denied your request. The Plan 
says a PCD coded as E0675 is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided April 
26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the psychiatric diagnostic evaluation 
provided by an out-of-network provider on July 13, 2023, and the office visit provided by an out-of-network 
provider on August 10, 2023, and September 7, 2023. 
 
You asked the Plan to waive the cost sharing for the psychiatric diagnostic evaluation and the office visits. You 
say that you could not find an in-network provider. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for each out-of-network individual or group therapy in-person or telehealth visit. 
 You have been asked to pay a $184.16 coinsurance for the psychiatric diagnostic evaluation and the office 
visits ($368.32 allowed amount x .50 = $184.16). These items/services fall 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 cost sharing for the psychiatric diagnostic 
evaluation provided by an out-of-network provider on July 13, 2023, and the office visit provided by an out-of-
network provider on August 10, 2023, and September 7, 2023.