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

 
We decided that the Plan does not have to reduce the cost share for the PET scan and the radiation therapy 
services provided on July 13, 2023. 
 
You asked the Plan to reduce the cost share for the PET scan and the radiation therapy services. You say that 
you were not made aware of additional charges for the rendered 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 $195 
copayment for in-network advanced imaging services. You must also pay 20% coinsurance for in-network 
radiation therapy services. 
 You have been asked to pay a $195 copayment for the PET scan. You have also been asked to pay $1,114.83, 
which is 20% coinsurance of the allowed amount for the radiation therapy services ($5,574.14 allowed amount 
x 20% coinsurance = $1,114.83). You have been asked to pay a total of $1,309.83 ($195 copayment + 
$1,114.83 coinsurance = $1,309.83). These services fall within the outpatient hospital services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the cost share for the PET scan and the radiation therapy services provided on 
July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related accessories 
provided on August 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The file shows that the items at issue were provided in an ambulatory surgical center. Although this item may 
be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device and related accessories provided on 
August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 10, 2023, billed 
with procedure code 99213-25. 
 
You asked the Plan to pay for the practitioner 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. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that generally, whirlpool is a component 
of procedure codes 97597/97598 and should not be reported separately during the same encounter. Only when 
there is a separately identifiable service being treated by the therapist, and the documentation supports this 
treatment, would the service be considered for payment utilizing modifier -59 or a more specific modifier as appropriate (e.g., LT, RT, -XS, etc.). 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 10, 2023, billed with procedure 
code 99213-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visits, and the 
radiation therapy services provided from August 2, 2023, to September 11, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visits, and the radiation therapy services. 
You say that you disagree with the cost share. 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 $44 
copayment for services received from in-network specialist above level 1. Your contract with the Plan also 
clearly says that you must pay 20% coinsurance for radiation therapy. 
 
You have been asked to pay a $44 copayment for each specialist office visit provided on August 2, 2023, 
August 14, 2023, August 16, 2023, August 21, 2023, August 23, 2023, August 28, 2023, September 6, 2023, 
and September 11, 2023. These services fall 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.  
 
You have also been asked to pay 20% coinsurance of the allowed amount for each radiation therapy service 
provided on August 2, 2023, August 14, 2023, August 16, 2023, August 21, 2023, August 23, 2023, August 28, 
2023, September 6, 2023, and September 11, 2023. These services fall within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category.  
 
Date of Service Service Allowed Amount 20% Coinsurance 
August 2, 2023 Radiation therapy service $364.70 $72.94 
August 2, 2023 Radiation therapy service $54.27 $10.85 
August 14, 2023 Radiation therapy service $216.92 $43.38 
August 14, 2023 Radiation therapy service $32.91 $6.58 
August 16, 2023 Radiation therapy service $32.91 $6.58 
August 21, 2023 Radiation therapy service $27.97 $5.59 
August 23, 2023 Radiation therapy service $27.97 $5.59 
August 28, 2023 Radiation therapy service $27.97 $5.59 
September 6, 2023 Radiation therapy service $32.91 $6.58 
September 11, 2023 Radiation therapy service $32.91 $6.58 
 
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 visits, and the radiation therapy 
services provided from August 2, 2023, to September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415 billed for date of service August 23, 
2023. 
 You asked the Plan to pay for procedure code 64415. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64415 is bundled into payment for code 01638. 
 
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 64415 
is a column II code to column I code 01638. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 64415 billed for date of service August 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-Ray exams provided on May 31, 2023 
and June 27, 2023. 
 
You asked the Plan to waive the copayments for X-Rays. You say that your doctor's office does not have this 
service available. 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 $85 
copayment for X-Ray exams at an outpatient hospital. There were two dates of service, resulting in a total 
copayment amount of $170. 
 
You have been asked to pay $85 copayment for X-Rays. This item/service falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for X-Ray exams provided on May 31, 2023 and June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician serivces provided on December 8, 2022, by an 
out-of-network (OON) provider.  
 You asked the Plan to pay for these services. You say that the physician is assigned to the facility. The Plan 
denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The file shows that the enrollee was 
receiving custodial care at the facility and this care is not covered. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician serivces provided on December 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit provided on August 18, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the hospital visit. You say that the provider and enrollee had no opportunity to 
choose a participating provider. The Plan denied your request. The Plan says that their original decision to deny 
payment was correct. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a hospital visit provided on August 18, 2023, by 
an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the upper extremity without contrast (73221). 
 
You asked the Plan to pre-approve an (MRI). The Plan denied your request. The Plan says the clinical records 
do not indicate what the physicians are looking for medically via an MRI. The Plan says the enrollee has not 
tried physical therapy and the injection done in July was only for the right shoulder as noted in the clinical 
records. The Plan says physical therapy may help with managing symptoms associated with the left shoulder 
(and possibly right shoulder as well). 
 
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). Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the most recent physical exam findings do not 
support significant red flag findings of the left shoulder and does not reveal that the enrollee has failed formal 
physical therapy. The requested left shoulder MRI is not medically 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 an (MRI) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the upper extremity without contrast (73221).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the CT scan provided on September 3, 
2023. 
 You asked the Plan to reduce the copayment for the CT scan. You say that your copayment should only be $90 
because you were seen in the emergency department. 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 that if advanced 
imaging services (such as CT, (CTA), (MRI), (MRA), nuclear stress test, (PET) scans, (SPECT)) are received 
as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not 
the emergency room copayment. It also says that enrollees must pay a $225 copayment for advanced imaging 
service (not including x-rays). 
 
You have been asked to pay a $225 for the CT scan. This item/service falls within the emergency care and 
advanced imaging 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 CT scan 
provided on September 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service (A0998) provided 
on August 29, 2023. 
 
You asked the Plan to waive the copayment for the ambulance service (A0998). 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 $265 
copayment for ambulance services. 
 
You have been asked to pay a $265 copayment for the ambulance service (A0998). 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service (A0998) provided on August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 31, 
2023. 
 You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 81456 billed for date of service May 31, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the biopsy of skin (11106), surgical pathology (88305) and an office 
visit (99214) provided on January 6, 2023. 
 
You asked the Plan to pay for the surgical services. You say that your provider referred you to get these 
services. You were in pain, and it was impossible to walk or put pressure on your foot. The Plan denied your 
request. The Plan says that an itemized bill was requested from your provider but was not received. 
 
The Plan must follow Medicare rules. The rules say that services and referrals given by a contract provider are 
considered approved by the Plan unless notice is provided that the services will not be covered. 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. Specifically, the enrollee argues that the ordering/referring provider is contracted 
with the Plan. The Plan did not reply to our request for information or provide documentation regarding the 
referring providers participation status. Therefore, we decided that the Plan has to pay for the biopsy of skin 
(11106), surgical pathology (88305) and an office visit (99214) provided on January 6, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport billed with codes A0130 and S0125 
for August 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 5, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance transport billed with codes A0130 and S0125 
for August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on August 1, 2023. 
 
You asked the Plan to pay for physician visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that I60.9 has an Excludes1 note in relation to S06.5XAA. This means that the 
two diagnosis codes cannot be reported together. All diagnosis codes within the category Cerebrovascular 
Diseases (I60-I69) have an Excludes1 note in relation to S06.- codes. Based on this information, we decided 
that the Medicare billing rules for physician visit have not been met. Therefore, we decided that the Plan does 
not have to pay for a physician visit provided on August 1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on August 29, 2023, to August 30, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you disagree with 
the cost share. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency department 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 copayment for the 
emergency department visit provided on August 29, 2023, to August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 24, 2023, billed with 
procedure code Q4262-76. 
 
You asked the Plan to pay for the practitioner 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 Q4262-76 is dual layer impax membrane, per square 
centimeter. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the medical documentation does state 
that amniotic membrane was used to aide in the wounds management, however the dimension of the allograft 
was not listed in the documentation and could not be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 24, 2023, billed with procedure code 
Q4262-76.