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

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on August 25, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you cannot 
afford to pay the copayment, you would like it waived or reduced. 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 $300 
copayment for advanced imaging services. 
 
You have been asked to pay a $300 copayment for the computed tomography (CT) scan. This item/service falls 
within the advanced imaging 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 computed tomography (CT) scan provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of amniotic membrane on the ocular surface 
provided on December 05, 2022. 
 
You asked the Plan to pay for the placement of amniotic membrane on the ocular surface. You say that you 
were told that prior authorization was 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 the placement of 
amniotic membrane on the ocular surface provided on December 05, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 11, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you fell over a 
cement block at the same facility as the emergency room. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on July 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with 81539-GZ for date of service 
October 3, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this cannot be paid with the billed modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier GZ is used for items or services 
expected to be denied as not reasonable and necessary. Lines with this modifier are submitted as non-covered 
and will be denied. 
 
We looked at the file and Medicare rules. The service at issue was submitted with modifier GZ and therefore 
cannot be covered. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
billed with 81539-GZ for date of service October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 876540 billed for date of service August 18, 
2023. 
 
You asked the Plan to pay for procedure code 876540. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 876540 is bundled into payment for code 87641. 
 
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 
876540 is a column II code to column I code 87641. The -59 modifier is not supported as a separate and 
distinct procedural service. 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 876540 billed for date of service 
August 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 28, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for immunohistochemistry (88341, 15 units) provided on August 16, 2023. 
 
You asked the Plan to pay for 88341. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that this code has a medically unlikely edits (MUE) value of 13 and the additional 
units are not supported. 
 
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. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot 
be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
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 received medical records related to this testing; however, the Plan did 
not submit the medical records to us for review. Without medical records, we cannot determine whether the 
number of units billed for code 88341 are supported. Therefore, we decided that the Plan has to pay for 
immunohistochemistry (88341, 15 units) provided on August 16, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the infusion therapy on June 27, 2023, to 
July 7, 2023.  
 
You asked the Plan to waive the copayments for the infusion therapy. You say that you believe someone should 
have told you that you were going to be responsible for 20% of this drug for the 11 days after being released. 
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 $320 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. For date of service June 
27, 2023, to June 30, 2023, the provier billed in the amount of $692 and the allowed amount $209.61. This is 
less than the copayment amount. There were four visits. For the service it's 4 x $209.61 = $838.44. For date of 
service July 1, 2023, to July 7, 2023, the provier billed in the amount of $692 and the allowed amount is 
$213.89. This is less than the copayment amount. There were seven visits. For the service it's 7 x $213.89 = 
$1,497.23. For all services it's $838.44 + $1,497.23 = $2,335.67. Therefore, results in the total cost sharing 
amount of $2,335.67. 
 
You have been asked to pay a $2,335.67 cost share for the infusion therapy. This item/service falls within the 
outpatient surgery and other medical 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 copayments for the infusion therapy on June 27, 
2023, to July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code V5275 billed for date of service August 10, 2023. 
 
You asked the Plan to pay for code V5275. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the billed code is not supported by the medical records. 
 
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 V5275 is Ear impression, each. 
 
We find that CPT code V5275 is not supported in the medical record. Specifically, the code at issue represents 
the taking of the ear impression in order to create hearing aids. The records you provided to support payment were scant.  You only provided a medical clearance form and an audiometric hearing test.  There is no 
documentation supporting the taking of ear impressions. Without this documentation, code V5275 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of code V5275 have not been 
met. Therefore, we decided that the Plan does not have to pay for code V5275 billed for date of service August 
10, 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 June 26, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. 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 two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 23, 2023, by an out-
of-network (OON) provider.  
 You asked the Plan to pay for practitioner services. You say that you contacted the enrollee's primary care 
provider, but the enrollee self-referred to your office for treatment. 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 practitioner services provided on August 23, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac-joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac-joint injection. You say that the requested service is a necessity 
for your care. The Plan denied your request. The Plan says the requested service 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 pre-approve a sacroiliac-joint injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of a positive response (reproduction of the enrollee's 
typical sacroiliac-joint pain) to at least 3 of the following provocative tests/maneuvers: Compression test, 
Distraction test, FABER test (also referred to as Patrick test), Gaenslens test and/or thigh thrust test (also 
referred to as posterior pelvic pain provocation or Yeoman test). 
 
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 sacroiliac-joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac-joint injection (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 22, 2023, billed with 
procedure code G0509. 
 
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 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 K92.2 has an Excludes1 note in relation to K26.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on June 22, 2023, billed with procedure code G0509.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88331 provided on June 13, 2023. 
 
You asked the Plan to pay for procedure code 88331. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 88331 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 88331. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88331 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88331 provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the presbyopia correcting function of intraocular 
lens (V2788) provided May 25, 2023. 
 
You asked the Plan to reimburse you for the presbyopia correcting function of intraocular lens. You say that 
you are requesting reimbursement of $2000.00 for the payment you already made to the surgeons office. The 
Plan denied your request. The Plan says the presbyopia-correcting feature of an IOL is not covered by 
Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to reimburse you for the presbyopia 
correcting function of intraocular lens (V2788) provided May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 19, 2023, by an 
out-of-network (OON) provider.  
 You asked the Plan to pay for telehealth services. You say that the enrollee was residing in a nursing facility 
and was unable to choose their 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 telehealth services provided on September 19, 
2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95940, 95938 and 95870 billed for date of 
service May 18, 2023. 
 
You asked the Plan to pay for procedure code(s) 95940, 95938 and 95870. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says codes 95938 and 95870 are included in 
the facility payment and are not separately payable. Code 95940 is an add-on 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. Technical components must be billed by the 
facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938 and 95870. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95938 and 
95870. Based on this information, we decided that Medicare rules for coverage of procedure codes 95938 and 
95870 have not been met. Furthermore, we have confirmed that code 95940 is an add-on code and has not been 
billed with an appropriate, payable primary procedure code. 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(s) 
95940, 95938 and 95870 billed for date of service May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81001 billed for date of service September 6, 
2023. 
 
You asked the Plan to pay for procedure code 81001. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81001 is bundled into payment for code G0483. 
 
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 81001 
is a column II code to column I code G0483. 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 81001 billed for date of service September 6, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on August 
09, 2023. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the emergency room doctor 
transferred you to another medical center for care and the policy says the emergency room copayment is 
waived if you are admitted to the hospital. 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 $110 
copayment for emergency care.  
You have been asked to pay a $110 copayment for 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. The records show you were not admitted to the same hospital where the emergency room visit was 
provided. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit 
provided on August 09, 2023.