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

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan, a 
chest x-ray, and an electrocardiogram (EKG) provided on August 10, 2023. 
 
You asked the Plan to waive the copayments for a CT scan, an x-ray, and an EKG. You say that this was 
supposed to be part of a preoperative service for surgery. There should not be a copayment for any of these. 
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 $35 
copayment, and a $150 copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay a $160.11 total copayment for a CT scan, and x-ray, and an EKG ($98.27 CT + 
$35 x-ray + $26.84 EKG = $106.11 total).  
 
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 a computed tomography (CT) scan, a chest x-
ray, and an electrocardiogram (EKG) provided on August 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our physician reviewer 
found that the enrollee has osteoarthritis of the knee. The Plan requires a trial of Orthovisc or Supartz FX 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 13, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 32557. 
 
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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service July 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the colonoscopy and the biopsy provided on 
September 28, 2023. 
 
You asked the Plan to waive the cost share for the colonoscopy and the biopsy. You say that this was a routine 
screening and should be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 deductible that applies to an in-network colonoscopy and the 
biopsy.  
 
A total of $505.58 was applied to satisfy the remainder of your deductible. The item or service you asked the 
Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 deductible which applies to an in-
network colonoscopy and biopsy. This cost sharing is a contractual obligation that had not been met at the time 
the colonoscopy and the biopsy was received on September 28, 2023.  
 
After the deductible was satisfied the remaining allowed amount is $511.58 ($1,017.16 original allowed 
amount - $505.58 = $511.58 remaining allowed amount). You have been asked to pay $51.16, which is 10% 
coinsurance of the allowed amount for these services ($511.58 remaining allowed amount x 10% coinsurance = 
$51.16). You have been asked to pay a total of $556.74 ($505.58 deductible + $51.16 coinsurance = $556.74). 
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 colonoscopy and the biopsy provided on September 28, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery at an outpatient 
hospital provided on September 06, 2023. 
 
You asked the Plan to reduce the copayment for the cataract surgery at an outpatient hospital. 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 $100 
copayment for outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $100 copayment for the cataract surgery at an outpatient hospital. This item/service falls within the outpatient surgery, including services provided at hospitaloutpatient 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 reduce the copayment for the cataract 
surgery at an outpatient hospital provided on September 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on June 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on March 
21, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. 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 surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $175 copayment for the outpatient surgery. This item/service falls within the outpatient surgery, including services provided at hospitaloutpatient 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. 
However, since the allowed amount is less than the copayment, you only owe $136. Therefore, we decided that 
the Plan does not have to waive the copayment for the outpatient surgery provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87471, 87500, 87640, 87641, 87651, and 
87653 billed for date of service March 27, 2023.  
 
You asked the Plan to pay for procedure codes 87471, 87500, 87640, 87641, 87651, and 87653. You say that 
you would like the Plan to reconsider their denial of payment. 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 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.  
 
In this case, the MUE for CPT codes 87471, 87500, 87640, 87641, 87651, and 87653 is 1. The MAI value for 
these codes is 3. You billed 2 units of each of these codes, exceeding the MUE. You did not provide all the 
required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 87471, 87500, 87640, 87641, 87651, and 87653 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87471, 87500, 87640, 87641, 87651, and 87653 billed for date of 
service March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic image (D0350) provided on September 
5, 2023. 
 
You asked the Plan to pay for the dental service. You say that the 2D photograph was done instead of an x-ray 
to avoid x-ray exposure and you were told it was a safer option. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the 2D photographic image is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
photographic image (D0350) provided on September 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0138 billed for date of service August 3, 
2023.   
You asked the Plan to pay for procedure code Q0138. 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 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.  
 
In this case, the MUE for CPT code Q0138 is 510. The MAI value for this code is 3. You billed 1,530 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code Q0138 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code Q0138 billed for date of service August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
September 27, 2023, to October 26, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $20 
copayment for outpatient diagnostic tests/radiology services. 
 
You have been asked to pay a $20 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/radiology 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 amount you owe is $440 ($20 x 22 visits = $440). 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient diagnostic test 
provided on September 27, 2023, to October 26, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 87900) rendered on May 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there was no quantitative infectious agent drug susceptibility completed. 
 
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 87900 is ""Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics." 
 
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. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the provided records for this case 
indicate that a respiratory pathogens panel was collected on May 12, 2023, and finalized on May 16, 2023. The 
panel included a polymerase chain reaction assay for various infectious agents (showing presence of 
Staphylococcus aureus and Parainfluenza Virus 1,3) with a drug susceptibility phenotype prediction using 
regularly updated genotypic bioinformatics (as detailed in the description of the test procedure and disclaimer). 
Criteria for coverage for CPT 87900 appears to be documented in this case.  
 
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 have been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 87900) rendered on May 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
May 29, 2023, to June 03, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you did not receive all 
the services in the claim. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a total of $1,950 for the inpatient hospital stay ($325 
copayment x 6 days = $1,950). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on May 29, 
2023, to June 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 14, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration stating the 
service was performed to hasten definitive diagnosis and efficiently treat patients condition. 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 January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 5, 
2023. 
 
You asked the Plan to pay for procedure code 99070. The Plan denied your request. The Plan says procedure 
code 99070 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services (procedure code 88300) rendered 
on March 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says reporting both procedure code 88300 and procedure code 88305 represents a duplication of 
services, since both procedures include the gross examination of the specimen. 
 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 88300 is "Level I - Surgical pathology, gross examination 
only." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider performed a 
pathology, gross and microscopic examination, however billing twice for the gross examination resulted in 
duplicate billing. In this case, separate payment for another gross examination cannot 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical pathology services (procedure code 88300) rendered on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease related services provided on 
August 31, 2023. 
 
You asked the Plan to pay for the end-stage renal disease related services. 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 end-stage renal 
disease related services provided on August 31, 2023.