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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 11, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. Urine PCR amplification techniques raise considerable 
concerns regarding contamination from one specimen to another, creating the potential for false-positive 
results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms 
representing latent infection or colonization cannot be distinguished from active, clinically significant 
infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus 
further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative 
predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel provided on April 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine 
(72148). 
 
You asked the Plan to pre-approve an MRI of the lower spine. You say that the MRI is medically necessary 
because weakness has spread and the provider suspects some of the enrollee's pain is coming from her hips as 
well as her back. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval 
of an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the lower spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there was an MRI done 
one year ago. There is not enough clinical information to justify the need for a repeat MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
March 8, 2023. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that outpatient intravenous insulin therapy was billed with CPT codes 96365 and 96366. These 
services are not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 96365 and 96366 billed for date of service March 8, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy is 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 a wireless capsule endoscopy. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has Iron 
deficiency anemia (IDA) and has completed esophagogastroduodenoscopy (EGD) and colonoscopy with no 
clear source. The next reasonable and indicated testing would be a video capsule endoscopy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a wireless capsule endoscopy have been met. Therefore, we decided that the 
Plan has to pre-approve a wireless capsule endoscopy (91110).   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on March 27, 2023, billed with 
code 44799. 
 
You asked the Plan to pay for the services as billed. You say that this was medically necessary and billed 
correctly. The Plan denied your request. The Plan says this code is 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 44799 is unlisted procedure, small intestine. 
 
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 as billed. Our reviewer says that the operative 
report does not support the billed code. Our reviewer found the medical record does not include documentation of the procedure being reported with an unlisted code. In this case, services were provided on the date of 
service billed, but it is unclear what procedure(s) are being reported and why an unlisted code is used.  
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on March 27, 2023, billed with code 44799.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a rollator walker (E1399). 
 
You asked the Plan to pre-approve a rollator walker. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan does not provide anything to show that the requested rollator transport 
chair has casters under 5 inches. Therefore, we decided that the Plan has to pre-approve a rollator walker 
(E1399).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided at 
an outpatient hospital provided on March 01, 2021, to March 16, 2021. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit provided at an outpatient 
hospital. You say that you believe that you should not owe a copayment because of the horrible treatment you 
experienced. 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 rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit provided at an outpatient 
hospital. This item/service falls within the outpatient rehabilitation 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. The total copayment you owe is $80 
for PT visits ($40 per visit x 2 visits = $80). Therefore, we decided that the Plan does not have to waive the 
copayment for each physical therapy (PT) visit provided at an outpatient hospital provided on March 01, 2021, 
to March 16, 2021.
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 January 12, 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 codes 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 or 87150; 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 the records provided do not support the use of the XU modifier with these codes. Our 
reviewer found the medical records do not include sufficient evidence to support that these services were 
performed as separate, distinct services independent of 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 January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an office visit provided on May 12, 2023. 
 
You asked the Plan to reduce the copayment for an office visit. You say that you have always paid $15 for 
urgent care visits. 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 $30 
copayment for each Medicare-covered urgent care facility visit. 
 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the each 
Medicare-covered urgent care facility 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. Therefore, we decided that the Plan does not have to reduce the copayment 
for an office visit provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 31, 2023. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on March 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for medical supply used in a position 
emission tomography (PET) scan provided on January 26, 2023. 
 
You asked the Plan to reduce the coinsurance for medical supply used in a position emission tomography 
(PET) scan. You say that all charges related to the PET scan should have been part of the responsibility. 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 medical supply used in a position emission tomography 
(PET) scan. 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 coinsurance you owe is 
$1,071.60, which is 20% of the allowed amount for a chemical agent used in a PET scan ($5,358 allowed x 
20% = $1,071.60). Therefore, we decided that the Plan does not have to reduce the coinsurance for medical 
supply used in a position emission tomography (PET) scan provided on January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to their most recent diagnosis, the 
enrollee meets the LTACH criteria and is too medically complex for a lower level of care. The Plan denied 
your request. The Plan says the level of care provided in the LTACH setting is more than the enrollee's medical 
conditions need.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be responding to current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on March 31, 2023, billed with 
procedure code 95937-26. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95937-26 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the procedure report does not include 
documentation of neuromuscular junction testing.  
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on March 31, 2023, billed with procedure code 95937-
26.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy provided on June 21, 2023. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy (EGD) with biopsy. You say 
that you were not told that there would be a 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 $280 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $280 copayment for an esophagogastroduodenoscopy (EGD) with biopsy. 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. Therefore, we decided that the Plan does not have to waive the copayment for an 
esophagogastroduodenoscopy (EGD) with biopsy provided on June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an x-ray provided on March 30, 2023. 
 
You asked the Plan to waive the coinsurance for an x-ray. You say that you say that you were quoted a 
different price. 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 40% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance 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. The total you owe is $94.67 ($236.68 allowed amount x 40% = $94.67). Therefore, we decided that the Plan does not have to waive the coinsurance for an x-ray provided on 
March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on January 25, 2023, 
to February 23, 2023. 
 
You asked the Plan to waive the coinsurance for injections. You say that you disagree with the cost share 
applied. 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 Medicare Part B prescriptions drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Medicare Part B 
prescriptions drugs 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 $919.52, which is less than 20% of the allowed amount for Medicare Part B 
drug injections because you met your maximum out-of-pocket with the processing of this claim. Therefore, we 
decided that the Plan does not have to waive the coinsurance for injections provided on January 25, 2023, to 
February 23, 2023.