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

 
We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (ERCP) 
(43277-59) provided on May 24, 2023. 
 
You asked the Plan to pay for ERCP 43277-59. You say that the -59 modifier allows this code to unbundle 
from other services. The Plan denied your request. The Plan says this code is inclusive to 43264 and use of the 
-59 modifier is 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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not show that this ERCP was a separate and distinct procedure service 
from the ERCP code 43264 performed on the same date of service to which 43277 is inclusive. Based on this 
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been 
met. Therefore, we decided that the Plan does not have to pay for endoscopic retrograde 
cholangiopancreatography (ERCP) (43277-59) provided on May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network urgent care visit 
provided on January 28, 2023. 
 
You asked the Plan to reduce the copayment for an out-of-network urgent care visit. You say that you had been 
to urgent care earlier in the year and it was a $40 copayment. Why is it more now? 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for an out-of-network urgent care visit. This item/service falls 
within the 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 reduce the copayment for 
an out-of-network urgent care visit provided on January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 29, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 an office visit provided 
on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on July 24, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are 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 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 the drug testing provided on July 24, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service June 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the claim. The Plan 
denied your request. The Plan says there is no documentation how the results will impact treatment. 
 
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 looked at the file and the rules. The records show that a comprehensive pharmacogenetics and hereditary 
cardio panel test was provided. The provided testing was reportedly ordered to make decisions about the 
enrollees medications. Medications should be provided based on a diagnosis and adjusted based on a response 
to the medication. Genetic markers may or may not correlate with actual clinical findings. The medical records 
do not show that the panel testing was part of the enrollees treatment plan. A physician attestations by itself 
does not provide sufficient documentation of medical necessity. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the panel testing billed for date of service June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided by an out-of-
network provider on August 23, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that the enrollee did not seek out-of-
network services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network lab services. 
 
The items or services you asked the Plan to waive the deductible for were provided by an out-of-network 
provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to out-of-network lab services. This cost sharing is a contractual obligation that had 
not been met at the time the lab services were received on August 23, 2023. Therefore, we decided that the Plan 
does not have to waive the deductible for the lab services provided by an out-of-network provider on August 
23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and clearly exceeds 
the Medicare established defining criteria for an appropriate long term acute care hospital admission  The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently 
unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with myocardial ischemia, underwent an operative 
procedure, and has had a complicated post-operative course.  The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. 
The enrollee continues to receive acute care services and these have not been denied. The medical record does 
not indicate that the enrollee requires services that they are not currently receiving but that would be available 
at the LTACH facility. The elements of coverage rules are not satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy sessions. 
 
You asked the Plan to pre-approve the therapy services. You say that 12 additional physical therapy sessions 
are reasonable and necessary. The Plan denied your request. The Plan says 12 additional physical therapy 
sessions are not reasonable and necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the request from therapy does not support an additional course of 
therapy based on enrollee's current condition or response to prior therapy. A home exercise program is likely 
effective. The plan has approved 4 sessions to allow re-assessment and instruction in a home exercise program.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urology services provided from February 2, 2023, to 
February 16, 2023, by an OON provider. 
 
You asked the Plan to pay for the urology services. You say that you are requesting reconsideration of the 
denied claims. The Plan denied your request. The Plan says these services were not authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the urology services provided from February 2, 2023, to February 16, 2023, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care office visit provided on 
August 13, 2023. 
 
You asked the Plan to waive the copayment for an urgent care office visit. You say that you were told that you 
would not have a 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 $45 
copayment for in-network urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care office visit. This item/service falls within the 
in-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 
an urgent care office visit provided on August 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on May 
04, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. 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 a home or residence visit 
for the evaluation provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95999, 95861 and 95868 billed for date of 
service May 9, 2022.  
 
You asked the Plan to pay for procedure codes 95999, 95861 and 95868. You say that the claim is billed 
correctly and should be paid. The Plan denied your request. The Plan says the billed number of units are not 
supported by the records as both provided and medically necessary. Code 95999 is not supported by 
documentation. 
 
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. The rules also say that providers/suppliers must report services correctly. Procedures should be reported 
with the Current Procedural Terminology (CPT) code that describes the services performed.  
 
In this case, the MUE for CPT codes 95861 and 95868 is 1. The MAI value for these codes is 3. You billed 2 
units of these codes, exceeding the MUE. In addition, the CPT Code Manual definition of code 95999 is 
unlisted neurological or neuromuscular diagnostic procedure. 
 
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 95999, 95861 and 95868. Our reviewer says 
that the services at issue in this case are not supported by the medical records. Our reviewer found that the 
documentation does support that additional units were performed, but not why they were medically necessary. 
Documentation does support CPT code 95999.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95999, 95861 and 95868 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 95999, 95861 and 95868 billed for date of service May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable pads (T4535).  
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable pads (T4535).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services described by code 99310 
billed for date of service March 20, 2023. 
 
You asked the Plan to pay for 99310. You say that 99310 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says that 99310 is denied because it is not supported in 
the documentation. 
 
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 99310 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. 
 
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 99310. Our reviewer says that 99310 is 
supported in the documentation. Our reviewer found the enrollee was seen in nursing home by a physician. The 
physician was managing chronic conditions such as dementia and hypertension. Code status was addressed. 
Documentation supports high complexity of medical decision making. An appropriate history and physical 
exam were performed. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99310 have been met. Therefore, we decided that the Plan has to pay for the 
evaluation and management services described by code 99310 billed for date of service March 20, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on March 29, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you did not 
request the scan and relied on the provider to request the necessary approval. 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. 
 
You have been asked to pay a $175 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient 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 copayment 
for a magnetic resonance imaging (MRI) provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary as the enrollee is barely eating and extremely malnourished. The Plan denied your request. The Plan 
says it is not safe for the enrollee to leave the hospital at this time because their respiratory status is getting 
worse due to pneumonia. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has superior mesenteric artery stenosis and underwent diagnostic 
laparoscopy. They have an ileus, pneumonia, hypoxia requiring bilevel positive airway pressure (BiPAP), and worsening mental status. It is not safe for the enrollee to be transferred. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolotherapy provided on August 21, 2023. 
 
You asked the Plan to pay for prolotherapy. You say that you are requesting reconsideration for 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 prolotherapy provided 
on August 21, 2023.