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

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
September 07, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 $200 
copayment for outpatient diagnostic tests/advanced imaging service. 
 
You have been asked to pay a $200 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/advanced imaging service benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an outpatient diagnostic tests provided on September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 26, 2023, billed with 
procedure codes 99100, 64447-59-, and 64450-59. 
 
You asked the Plan to pay for practitioner services. You say that the claim is billed correctly. The Plan denied 
your request. The Plan says codes 64447-59 and 64450-59 are not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 
 
 
 
 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 practitioner services. Our reviewer says that 
the services do not meet criteria for billing or reimbursement consideration. Our physician reviewer found 
Current Procedural Terminology (CPT) 64447 and 64450 have a bundled relationship with CPT 01402 which 
was also performed on June 26, 2023. The medical records provided does not include sufficient documentation 
to validate that the peripheral nerve block was rendered only for post-operative pain management and that it 
was unrelated to the anesthesia provided to the surgery itself, therefore this procedure cannot be verified and 
the use of a 59 modifier to unbundle this service would not be appropriate. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of practitioner services have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on June 26, 2023, billed with procedure codes 99100, 
64447-59-, and 64450-59.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the external mobile cardiovascular telemetry 
on January 24, 2023.  
 
You asked the Plan to waive the cost share for the external mobile cardiovascular telemetry. You say that you 
don't feel that this is correct and that the health plan should pay it. The Plan denied your request. The Plan says 
this cost sharing was charged correctly.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance of the approved amount for all other services for diagnostic tests. The annual deductible applies. 
There is a $703.07 deductible and a $90.77 coinsurance. For the service it's $703.07 + $90.77 = $793.84. 
Therefore, results in the total cost sharing amount of $793.84. 
 
You have been asked to pay a $793.84 cost share for the external mobile cardiovascular telemetry. This 
item/service falls within the 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. Therefore, we decided that the Plan does not have to waive the cost share 
for the external mobile cardiovascular telemetry on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eye refraction provided on August 15, 2023. 
 
You asked the Plan to pre-approve the eye refraction. You say that you have an eye checkup every 6 months 
because you have diabetes. You also say that you believe the eye refraction was part of the routine service. The 
Plan denied your request. The Plan says refractive services are not covered under your medical benefit plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The 2023 Evidence of Coverage clearly states that eye refractions are 
not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pre-approve the eye 
refraction provided on August 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on February 25, 
2023. 
 
You asked the Plan to pay for 99285. You say that 99285 accurately reflects the services provided. The Plan 
denied your request. The Plan says code 99285 is not supported so 99284 was paid instead. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
We asked our coding 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 99285. Our reviewer says that this code does 
not meet criteria for payment. Our reviewer found the record does not reflect high medical decision making. 
The record shows moderate medical decision making was performed. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit (99285) provided on February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were not told they were out-of-network. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on September 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78452 billed for date of service March 14, 
2023.  
 You asked the Plan to pay for procedure code 78452. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78452 is 1. The MAI value for this code is 2. Two (2) units have been 
billed of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 78452 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 78452 billed for date of service March 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization inpatient services provided on August 8, 
2023, to August 13, 2023. 
 
You asked the Plan to pay for post stabilization inpatient services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says they paid for all emergent 
care up to the point of stability.  
 
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 post stabilization inpatient services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the continued out-of-network inpatient admission beyond August 11, 2023, 
was not medically necessary for this beneficiary. Inpatient care is necessary when the enrollees signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the 
enrollee requires diagnostic studies in an inpatient setting, or if it is medically necessary for the enrollee to 
remain in the acute inpatient setting. The enrollee was treated emergently and had stabilized as of August 11, 
2023. At that time, the enrollee could have been transferred to an in-network provider for continued care in the 
inpatient setting. In this case, the documentation indicates the enrollee was stable and improved and could have 
been transferred to an in-network facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for post stabilization inpatient services provided on August 8, 2023, to 
August 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 4, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test billed for date of service March 16, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test is well established. The Plan denied your 
request. The Plan says the test is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file, and Medicare rules. We find that the requirements for Medicare reasonable necessity 
have not been met. Based on this information, we decided that Medicare rules for coverage of the billed testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder test billed for 
date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair of ectropion provided on September 01, 2023. 
 
You asked the Plan to pay for repair of ectropion. You say that this service is supported in the records proving 
medical necessity. 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 repair of ectropion 
provided on September 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the renal biopsy provided on August 15, 
2023. 
 
You asked the Plan to waive the copayment for the renal biopsy. You say that you should not have a 
copayment because the surgery was useless. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for the renal 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 the renal biopsy provided on 
August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 10, 2023. 
 
You asked the Plan to pay for lab testing. You say that the claim denied incorrectly. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on August 
07, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99214). 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 $15 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $15 copayment for the office visit (99214). This item/service falls within the 
Physician/Practitioner services, including doctors officevisits 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 office visit (99214) provided on August 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal 
provided on June 27, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that your 
insurance should have covered this as a preventive screening. 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $320 copayment for the colonoscopy with lesion removal. 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 the colonoscopy with 
lesion removal provided on June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic imaging provided on 
October 10, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for the diagnostic imaging. 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 copayment for the diagnostic imaging provided on October 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on January 14, 
2023. 
 
You asked the Plan to waive the copayment for emergency care. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency care. 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 emergency care provided on 
January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the shoulder brace provided on June 27, 
2023. 
 
You asked the Plan to waive the coinsurance for the shoulder brace. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the shoulder brace. This item/service falls within the durable 
medical equipment (DME) 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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the shoulder brace provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the lift recliner provided on June 22, 
2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the lift recliner. You say that you were not told an 
authorization would be required for prescribed equipment. The Plan denied your request. The Plan says this 
item was not authorized. 
 
 
 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 provide reimbursement 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 provide reimbursement for this 
item. Therefore, we decided that the Plan does not have to provide reimbursement for the lift recliner provided 
on June 22, 2023, by an OON provider.