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

 
We decided that the Plan does not have to pay for procedure codes 81003 and 83550 billed for date of service 
August 19, 2022. 
 
You asked the Plan to pay for procedure code 81003 and 83550. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 81003 is 
bundled into payment for code 81001. Additionally, payment for code 83550 is bundled into payment for 
84466. 
 
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 81003 
is a column II code to column I code 81001. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, we have confirmed that code 83550 is a column II code to column I code 84466 
with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 81003 and 83550 billed for date of service August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99221) provided on October 12, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is 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 find that CPT code 99221 is not supported in the medical record. Specifically, the code billed is included in 
the global surgery package for code 47562 which was billed on October 13, 2022 and has a global surgery 
period of 90 days. Based on this information, we decided that Medicare rules for coverage of the hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99221) provided 
on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nail clipping services provided on 
January 30, 2023. 
 
You asked the Plan to waive the copayment for the nail clipping services. You say that this was fully covered 
in the past. 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for the nail clipping services. This item/service falls within the 
podiatry 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 nail clipping 
services provided on January 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance image (MRI) 
provided on February 14, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance image (MRI). You say that you feel the 
services should be covered because it is very expensive and you are unable to afford 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 $350 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $350 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 $276.55, which is less than the standard $350 copayment 
for an MRI. Therefore, we decided that the Plan does not have to reduce the copayment for a magnetic 
resonance image (MRI) provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic tests provided on 
June 17, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient diagnostic tests. You say that you disagree with 
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 outpatient diagnostic tests. 
 
You have been asked to pay 20% coinsurance for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests 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 allowed amount for the outpatient diagnostic tests is $5,000. You are being asked 
to pay $1,000 ($5,000 x 20% = $1,000). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an outpatient diagnostic tests provided on June 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on December 29, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were told 
there was no copayment to be paid at the time of your visit but knew there would be at least a $40 copayment 
for the office 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 $225 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $225 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 $211.22, which is less than the standard $225 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on December 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal shock wave involving musculoskeletal system 
provided on May 05, 2022, to September 15, 2022. 
 
You asked the Plan to pay for extracorporeal shock wave involving musculoskeletal system. You say that the 
services 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 extracorporeal shock 
wave involving musculoskeletal system provided on May 05, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the complete eye exam provided on 
February 01, 2023. 
 
You asked the Plan to reduce the copayment for the complete eye exam. You say that you thought you would 
only have a $15 copayment for a routine eye 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 $40 
copayment for vision care. 
 
You have been asked to pay a $40 copayment for the complete eye exam. This item/service falls within the 
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 records show a complete eye exam was provided, and the copayment was applied correctly. 
Therefore, we decided that the Plan does not have to reduce the copayment for the complete eye exam provided 
on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
February 08, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you were told that you 
would be charged $10 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 the specialist office visit provided on February 08, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 19, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting the submitted documentation 
be reviewed. 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 physical therapy 
provided on August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 19, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say the services are not out of network. 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 lab testing provided on 
January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 29, 2022. 
 
You asked the Plan to pay for lab testing. You say that you say that the members labs were sent to you and 
therefore, the member is not using out of network benefits. 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 lab testing provided on 
December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heating pad (E0217) provided August 24, 2022 to 
September 13, 2022. 
 
You asked the Plan to pay for the heating pad. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say tha  it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The type of heating pad used is non-covered. Based on this 
information, we decided that Medicare rules for coverage of the heating pad have not been met. Therefore, we decided that the Plan does not have to pay for a heating pad (E0217) provided August 24, 2022 to September 
13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on February 10, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you feel as though the services should 
be covered because you did not eepect a copay this high for ambulance services. 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 ambulance service. 
 
You have been asked to pay a $325 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on February 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99409 provided on October 15, 2022. 
 
You asked the Plan to pay for procedure code 99409. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Procedure code 99409 has a status code of "N" under the Medicare 
Physicians Fee Schedule Database (MPFSDB) and is a non-covered service per Medicare guidelines. 
Therefore, we decided that the Plan does not have to pay for procedure code 99409 provided on October 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on July 29, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that the provider doubled the 
charges. 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 urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for the urgent 
care visit provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, and 83550) related to 
end-stage renal disease (ESRD) provided on December 29, 2022. 
 You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (82728, 83540, and 83550) related to end-stage renal disease 
(ESRD) provided on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). You asked the Plan to pre-approve the Freestyle Libre continuous glucose monitor. You say that the medical 
records support the medical necessity for the CGM. The Plan denied your request. The Plan says the enrollee is 
not receiving insulin and there is no documented evidence of hypoglycemic episodes so the continuous glucose 
monitor is not medically necessary and not covered by Medicare. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 Freestyle Libre continuous glucose 
monitor. Our reviewer says that the CGM is not medically necessary. Our physician reviewer found the 
enrollee is not using insulin and we are not told of low blood glucose sugar. We are also not told why a 
glucometer using finger sticks would not suffice for the clinical needs of the patient. 
 
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 Freestyle Libre continuous glucose monitor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay provided from 
June 24, 2021, to June 30, 2021. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that your plan covers this 
service at 100%. 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 $490 out-of-network deductible which applies to out-of-network 
inpatient hospital care. Your contract with the Plan also clearly says that you must pay 30% coinsurance after meeting the deductible for out-of-network inpatient hospital care. 
 
You have been asked to pay $490 toward the out-of-network deductible. The item or service you asked the Plan 
to waive the cost share for falls within the inpatient hospital care benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $490 out-of-network deductible which 
applies to out-of-network inpatient hospital care. This cost sharing is a contractual obligation that had not been 
met at the time the inpatient hospital stay was received on June 24, 2021.  
 
Due to meeting your out-of-pocket maximum, you have also been asked to pay $905, which is less than the 
standard 30% coinsurance for the inpatient hospital stay. This item/service falls within the inpatient hospital 
care benefit category. You have been asked to pay a total of $1,395 ($490 deductible + $905 coinsurance = 
$1,395). 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 the inpatient hospital stay provided from June 
24, 2021, to June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on December 19, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes J96.01 and R09.02 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 provided on December 19, 2022.