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

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service June 28, 
2023.  
 
You asked the Plan to pay for procedure code 87798. 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 code 87798 is 13. The MAI value for this code is 3. You billed 19 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 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and laparoscopy, surgical; 
with removal of adnexal structures provided on May 16, 2023. 
 
You asked the Plan to pay for laparoscopy, surgical, colpopexy and laparoscopy, surgical; with removal of 
adnexal structures. You say that the services were medically necessary. The Plan denied your request. The Plan 
says this provider is nonparticipating, and based on specialty and taxonomy is not eligible for Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and 
laparoscopy, surgical; with removal of adnexal structures provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 17000 and 17003 billed for date of service 
August 30, 2023. 
 You asked the Plan to pay for procedure codes 17000 and 17003. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for codes 17000 and 17003 is bundled 
into payment for code 17110. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
17000 and 17003 are column II codes to column I code 17110. 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 codes 17000 and 17003 billed for 
date of service August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinary tract infection comprehensive panel rendered on 
June 26, 2023. 
 
You asked the Plan to pay for the services. You say that each code is separately payable. The Plan denied your 
request. The Plan says the panel should not be unbundled. 
 
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 find that CPT codes 87481, 87491, 87496, and 87529 are not supported in the medical record. Specifically, 
laboratory panels should be reported with one code. 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 a 
urinary tract infection comprehensive panel rendered on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on September 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous dentist was no longer in-network 
so you had to go to a new dentist and they required x-rays. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid for the intraoral complete series of radiographic images (D0210) on May 3, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of May 3, 2023. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on September 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health physical therapy services provided from 
February 13, 2023, to March 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for home health physical therapy services. You say that authorization was received. 
The Plan denied your request. The Plan says that the authorization given was not for these dates of service. 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 home health physical therapy services provided 
from February 13, 2023, to March 8, 2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 31, 2023, to August 02, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that to please reconsider 
the denial of coverage of your recent hospital stay. 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 room services. 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 room 
services provided on July 31, 2023, to August 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service August 
17, 2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment for 
code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field examination provided on 
July 24, 2023. 
 
You asked the Plan to waive the copayment for the visual field examination. You say that you did not meet 
with the physician. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for vision care. 
 
You have been asked to pay a $40 copayment for the visual field examination. This item/service falls within 
the vision 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 visual field 
examination provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 10, 
2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for nursing facility care. You say that the enrollee was residing in a nursing facility 
when the service was rendered. 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 subsequent nursing facility care provided on 
August 10, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the podiatry services provided on August 
22, 2023. 
 
You asked the Plan to waive the deductible for the podiatry services. You say that you have not had to pay for 
this service in the past. 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 $750 deductible which applies to podiatry services.  
 
 
 
 
 You have been asked to pay $130.51 towards the deductible for the podiatry services. The item or service you 
asked the Plan to waive the deductible for falls within the podiatry services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
podiatry services. This cost sharing is a contractual obligation that had not been met at the time the podiatry 
services was received on August 22, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the podiatry services provided on August 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on June 21, 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 the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93620, 93621, & 93623 provided on July 
12, 2023. 
 
You asked the Plan to pay for procedure codes 93620, 93621, & 93623. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the documentation does not support the 
billed service. 
 
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 find that CPT codes 93620, 93621, 93623 are not supported in the medical record. Specifically, no 
operative report was provided for the billed date of service. The plan requested additional information and none 
was provided. Based on this information, we decided that Medicare rules for coverage of procedure codes 93620, 93621, & 93623 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 93620, 93621, & 93623 provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
May 18, 2023, to June 6, 2023.  
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 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. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218) provided May 18, 2023, to June 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member is only noted at this time to 
have a mild cognitive impairment (MCI). They are not noted to meet diagnostic criteria for either AD or FTD, 
let alone both. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 18, 2023, to  
June 13, 2023.  
 
You asked the Plan to pay for psychotherapy. You say that you were misled by the intake department. The Plan 
denied your request. The Plan says this provider is not an eligible provider type. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
May 18, 2023, to June 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the physical therapy visit (97140, 97110) provided on 
July 10, 2023. 
 
You asked the Plan to pay more for the physical therapy visit (97140, 97110). You say that the copayment 
should be $30.00. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for out-of-network Medicare-covered Physical Therapy in-person visits.  
 
The enrollee has been asked to pay a $36.77 for the physical therapy visit (97140, 97110). The Plans allowed 
amount for the services received was $73.54. The enrollee was asked to pay a coinsurance of  $36.77, which is 
50% of the allowed amount. This item/service falls within the outpatient rehabilitation services benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the physical therapy visit (97140, 97110) 
provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lumbar interlaminar epidural injection 
provided on July 28, 2023. 
 
You asked the Plan to waive the copayment for the injection. You say that you are requesting reconsideration 
of the copayment applied on this 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 $370 
copayment per day for outpatient surgery performed in an outpatient hospital.  
 
You have been asked to pay a $370 copayment for the epidural injection. This item/service falls within the outpatient surgery 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 lumbar 
interlaminar epidural injection provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 2, 2023, billed with 
procedure codes 64616 and 95874-26. 
 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 code 64616 was billed without the appropriate 
anatomical modifier, and code 95874 is an add-on code that was billed without a valid primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that hospitals should report the appropriate RT or LT 
modifier to identify which of the paired organs was operated upon. The rules also say that an add-on code is 
eligible for payment only if it is reported with an appropriate primary procedure performed by the same 
practitioner.  
 
We looked at the file and Medicare rules. We have verified that code 64616 has not been billed with the 
appropriate anatomical modifier. Add- on code 95874 has not been billed with a valid primary procedure.  
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 March 2, 2023, billed with procedure codes 64616 and 95874-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided 
June 26, 2023, and billed with codes 87481, 87500, 87640, 87652, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided June 26, 2023, and 
billed with codes 87481, 87500, 87640, 87652, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 
05, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told to go to the 
emergency room, and did not receive services at the urgent care. 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 $60 
copayment for out-of-network urgently needed services. 
 
You have been asked to pay a $60 copayment for the urgent care visit. This item/service falls within the out-of-
network urgently needed 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 urgent care visit provided on September 05, 2023.