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

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on May 01, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on May 01, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95937 and G0453 for date of service March 14, 2023. 
 
You asked the Plan to pay for codes 95937 and G0453. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 95937 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
The CPT Code Manual definition of code G0453 is continuous intraoperative neurophysiology monitoring, 
from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) 
each 15 minutes (list in addition to primary procedure). 
 We find that CPT codes 95937 and G0453 are not supported in the medical record. Specifically, the medical 
records submitted indicate that train of four testing was performed. CPT code 95937 was billed. Train of four 
testing does not fit the criteria for this code as it is inappropriate to bill the code for neuromuscular junction 
when train of four monitoring is performed. Code G0453 was billed with place of service 22 (On Campus-
Outpatient Hospital). The claims data indicates that the enrollee was inpatient at the time services were 
provided. Therefore, the place of service billed is not supported. Based on this information, we decided that 
Medicare rules for coverage of codes 95937 and G0453 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 95937 and G0453 for date of service March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87652, and 87798) provided on 
March 9, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87652, and 87798. 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 find that CPT codes 87481, 87652, and 87798 are not supported in the medical record. Specifically, a panel 
was performed and there is a more appropriate singular code for the services. 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 the panel testing (87481, 87652, and 87798) provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you incorrectly verified the enrollees coverage. 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 September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound debridement provided on June 
22, 2023. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that this should be considered 
an 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 $210 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $210 copayment for the wound debridement. This item/service falls within the 
outpatient surgery provided at 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. The record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the wound debridement provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services and chronic care management services provided on May 31, 2023, to July 31, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services and chronic care 
management services. 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 remote physiologic 
monitoring treatment management services and chronic care management services provided on May 31, 2023, 
to July 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (95811). 
 You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered when specific 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 polysomnography. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you had a negative home sleep 
study for OSA; therefore you do not require an additional sleep study per the documentation provided. There is 
no indication for a further sleep study given the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 05, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $325 
copayment for outpatient surgery/Medicare-coveredsurgery. 
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-coveredsurgery 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. However, since the allowed amount is less than the standard copayment, 
you only owe $272.82. Therefore, we decided that the Plan does not have to waive the copayment for an 
outpatient surgery provided on July 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
chest scan provided on June 21, 2023. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) chest scan. You say 
that please reprocess, I need this medically. 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 $115 
copayment for other outpatient diagnostic tests- radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $115 copayment for an in-network computed tomography (CT) chest scan. This item/service falls within the other outpatient diagnostic tests- radiological diagnostic services, not including x-
rays 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. 
However, since the allowed amount is less than the standard copayment, you only owe $108.87. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
chest scan provided on June 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
March 24, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you had no choice 
but to take an ambulance. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance transportation. This item/service falls within 
the ambulance 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. However, since the allowed amount is less than the standard copayment, you only owe 
$194.66. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance 
transportation provided on March 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the skin graft procedures and emergency 
room visit provided from April 27, 2023, to May 11, 2023. 
 
You asked the Plan to waive the cost sharing for the skin graft procedures and emergency room visit. You say 
that you want to appeal the cost sharing for these 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 $150 
copayment for outpatient surgery. Your contract with the Plan clearly says that you must pay a $125 
copayment for each emergency room visit. 
 
Date of Service Code Allowed Amount Copayment 
April 27, 2023 15275 $1,584.10 $150 
May 4, 2023 15275 $1,584.10 $150 
May 11, 2023 G0463 $110.93 $110.93 
Total $410.93 
 
You have been asked to pay a $150 copayment for each skin graft procedure. This item/service falls within the 
outpatient surgery benefit category. You have also been asked to pay $110.93, which is less than the standard 
$125 copayment for the emergency room visit. This item/service falls within the emergency care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the skin graft procedures and emergency room 
visit provided from April 27, 2023, to May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spinal fusion surgery (22612, 22614, 22558, 
22585). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for spondylolisthesis of the lumbar region. She presented with low 
back pain off and on for several years.   
 
 
More recently the pain has continued to increase and has caused significant difficulty with ambulation. She is 
only able to walk approximately 100 feet without needing to stop. Her pain is rated at 2/10. The exam reveals 
full range of motion on the lumbar spine. There is intact strength, sensation, and reflexes. 
 
However, the dynamic flexion/extension films did not demonstrate instability at the requested surgical level. 
Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative 
instability. The examination does not corroborate any neurological deficits. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested lumbar fusion at the L4-S1 levels is not medically reasonable 
or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar spinal fusion surgery (22612, 22614, 22558, 22585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection with image guidance provided 
on April 04, 2023. 
 
You asked the Plan to waive the copayment for an injection with image guidance. You say that you do not 
understand why you were billed differently. 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 $370 
copayment for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital.  
You have been asked to pay a $370 copayment for an injection with image guidance. This item/service falls 
within the other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic 
endoscopy, and outpatient surgery performed 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 an injection with image guidance provided on April 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor provided 
on June 05, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that you were told 
this would be fully 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous glucose monitor. This item/service falls 
within the durable medical equipment and related 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. The total you owe is $54.59 ($272.97 allowed 
amount x 20% coinsurance = $54.59). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the continuous glucose monitor provided on June 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cataract surgery provided on June 12, 
2023, to June 19, 2023. 
 
You asked the Plan to waive the copayment for each cataract surgery. You say that you say that when you 
called to find out how much you would be responsible for after cataract surgery on both eyes, you were told 
$290 for both eyes, now your being billed $290 for each eye. 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 $290 
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $290 copayment for each cataract surgery. This item/service falls within the 
outpatient surgery including services provided at hospital outpatient 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. The 
total you owe is $580 ($290 copayment x 2 visits = $580). Therefore, we decided that the Plan does not have to 
waive the copayment for each cataract surgery provided on June 12, 2023, to June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on January 
11, 2023, to February 08, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $250 
copayment for outpatient surgery/surgical center visit. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/surgical center visit 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 amount you are being asked to pay is $500 ($250 x 2 visits = $500). 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on January 11, 2023, to February 08, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you require SNF services to regain your prior level 
of functioning. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.