Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT codes 17311 and 17312 provided on December 20, 
2019. 
 
You asked the Plan to pay for CPT codes 17311 and 17312. You say that the medical records support the 
billing of CPT codes 17311 and 17312. The Plan denied your request. The Plan says the medical records do not 
support the billing of CPT codes 17311 and 17312. 
 
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 17311 is Mohs micrographic technique, including 
removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, 
microscopic examination of specimens by the surgeon, and histopathologic preparation including routine 
stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with 
surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue 
blocks. The definition of code 17312 is Mohs micrographic technique, including removal of all gross tumor, 
surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of 
specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and 
eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, 
cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks 
(List separately in addition to code for primary procedure). 
 
We find that CPT codes 17311 and 17312 are not supported in the medical record. Specifically, the medical 
records do not include documentation of mapping, color coding of specimens, microscopic examination of 
specimen by the surgeon, and histopathologic preparation including routine stain(s) to support the codes billed 
and the services cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
CPT codes 17311 and 17312 have not been met. Therefore, we decided that the Plan does not have to pay for 
CPT codes 17311 and 17312 provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy services provided on January 28, 
2020. 
 
You asked the Plan to waive the copayment for the therapy services. You say that you should only have to pay 
one copayment for this date of service. The Plan denied your request. The Plan says you received both 
specialist services and therapy services, so two separate copayments apply. 
 
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 $25 
copayment for each therapy service and a $30 copayment for each specialist service. 
 
Records show that on the date of service in question, you received both an occupational therapy service as well 
as services related to lymphedema strapping with a specialist. You have been asked to pay both a $25 
copayment for the therapy service and a $30 for the specialty (i.e., lymphedema strapping) service. This means 
that you have been asked to pay the correct amounts 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 therapy services provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation and specialist 
services provided on February 4, 2020. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation and specialist services. You say that 
you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have 
been applied. 
 
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 $25 
copayment for outpatient rehabilitation services/in-network and a $30 copayment for physician/practitioner 
services/in-network/specialist.  
 
You have been asked to pay a $25 copayment for outpatient rehabilitation and a $30 copayment for specialist 
services. The total amount you are being asked to pay is $55 ($25 + $30 = $55). The correct copayment has 
been applied to the services that were provided. Outpatient rehabilitation falls within the outpatient 
rehabilitation services/in-network benefit category. Specialist services falls within the outpatient rehabilitation 
services/in-network and 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 outpatient 
rehabilitation and specialist services provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you were unable to go to an in-state provider 
due to travel restrictions. The Plan denied your request. The Plan says there are contract providers who would 
have been able to provide the same services. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. There is no indication to show the services were 
urgent or emergent. There are insufficient records to show that the services could not wait until returning to the 
service area. The Plan did not pre-approve the services at issue. We found no exception that would require the 
Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services 
provided on April 6, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 15, 2019. 
 
You asked the Plan to pay for the ambulance services. Your daughter said that you became confused and afraid 
when the paramedics arrived and felt safe to have your daughter transport you to the hospital. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 15, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy and specialist services provided on 
February 18, 2020 by an out-of-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You are responsible for a $25.00 copayment for each Medicare-covered therapy visit and $30.00 copayment for 
services obtained from a specialist. Review of the file shows that you received both services at the same visit 
and providers may ask you for more than one cost share payment if you get more than one service at an 
appointment. 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 therapy and specialist services provided on 
February 18, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0194) provided on 
November 12, 2019. 
 
You asked the Plan to pay for the durable medical equipment (E0194). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the proof of delivery is not 
valid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (E0194) provided on November 
12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 4, 2020. 
 
You asked the Plan to pay more for dental services. You say that you were told you would receive a porcelain 
crown but received a bridge instead. You say that you were not consulted on the cost of the procedure. The 
Plan denied your request. The Plan says your annual allowance has been met. 
 
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, you also have an annual allowance of 
$3,000 for preventive and comprehensive dental services. The Plan has paid $3,000 toward dental services you 
received on March 4, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay more for dental services provided on March 4, 2020.  
 
Your complaint about dissatisfaction of the work is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry by partial coherence interferometry 
with intraocular lens power calculation (CPT Code 92136) provided on February 21, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 92136 26 LT (1 unit) remains not supported. The documentation 
submitted did not include documentation of ophthalmic biometry by partial coherence interferometry with 
intraocular lens power calculation was performed; therefore, the billed service cannot be verified. Of note the 
submitted medical records do not include intraocular lens power calculation sheet It is noted that multiple 
attempts were made to contact the provider for additional information. 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power 
calculation (CPT Code 92136) provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 30, 2018 through June 22, 
2018. 
 
You asked the Plan to pay for the services. You say that the claim was submitted several times and the claim 
was denied every time for untimely filing. The Plan denied your request. The Plan says the claim was not filed 
timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until May 28, 2019. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided from April 30, 2018 through June 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), anesthetic agent and/or steroid, transforaminal 
epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT Code 64483) and 
injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 
CT); lumbar or sacral, each additional level (CPT Code 64484) provided on February 18, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 64483 50 (1 unit) remains not supported. The documentation 
submitted did not include documentation of this service was performed bilaterally; therefore, the billed service 
cannot be verified. Of note, the submitted documentation indicates this procedure was performed only on the 
right side. It is noted that multiple attempts were made to contact the provider for additional information. We 
have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met. 
 
Current Procedural Terminology (CPT) code 64484 50 (1 unit) remains not supported.  The required primary 
service code (CPT code 64483) is denied in the claim processing system (Reason Code 191); therefore, this 
service cannot be reimbursed separately. In addition, the documentation submitted did not include 
documentation of this service was performed bilaterally; therefore, the billed service cannot be verified. Of 
note, the submitted documentation indicates this procedure was performed only on the right side. It is noted 
that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met. 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 injection(s), anesthetic agent and/or steroid, transforaminal 
epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT Code 64483) and 
injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 
CT); lumbar or sacral, each additional level (CPT Code 64484) provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code S9348 provided from December 27, 2019 to 
January 2, 2020. 
 
You asked the Plan to pay for CPT code S9348. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT code S9348 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for CPT code S9348 provided from December 27, 2019 to January 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76830 provided on February 5, 
2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by 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 76830 is ultrasound, transvaginal. 
 
We find that CPT code 76830 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation to support that a transvaginal ultrasound was performed. Based on this 
information, we decided that Medicare rules for coverage of the ultrasound services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound services coded 76830 provided on 
February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT codes 95937 and A4215 provided on March 2, 2020. 
 
You asked the Plan to pay for CPT codes 95937 and A4215. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 95937 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train 
of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is 
inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. 
There is no separate code for train of four monitoring. 
 
 
 
Furthermore, CPT code A4215 has a status code of "X" under the MPFSDB and represents a service that is not 
in the statutory definition of "physician services" for fee schedule payment purposes. Therefore, we decided 
that the Plan does not have to pay for CPT codes 95937 and A4215 provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 6, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 laboratory services provided on November 6, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services (99203, 72050, 72100, 
98943, 97124, 97039, and G0283) provided from November 21, 2019 to December 11, 2019. 
 
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the non-covered chiropractic services (99203, 72050, 72100, 98943, 
97124, 97039, and G0283) provided from November 21, 2019 to December 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from June 13, 2019 through June 30, 
2019. 
 
You asked the Plan to pay for the services. You say that the member was taken out of hospice on June 7, 2019. 
The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all 
Medicare covered services related or unrelated to the member's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 7, 2019. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided from 
June 13, 2019 through June 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP supplies provided on March 14, 2020. 
 
You asked the Plan to pay for the CPAP supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is ineligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services 
furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows the medical services were provided by a provider that 
has not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
CPAP supplies provided on March 14, 2020.