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

 
We decided that the Plan does not have to pay for molecular pathology procedures provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services do not meet coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for molecular pathology 
procedures provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thiamine hcl injection coded J3411, the  pyridoxine hcl 
injection coded J3415, and the vitamin b-12 cyanocobalamin injection coded J3420 provided on March 17, 
2020. 
 
You asked the Plan to pay for the thiamine hcl injection, the  pyridoxine hcl injection, and the vitamin b-12 
cyanocobalamin injection. 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. 
 
We find that CPT codes J3411, J3415, J3420 are not supported in the medical record. Specifically, the 
documentation supports that nutrition blend was administered. There is a more appropriate code for the 
services rendered. Based on this information, we decided that Medicare rules for coverage of the thiamine hcl 
injection, the  pyridoxine hcl injection, and the vitamin b-12 cyanocobalamin injection have not been met. 
Therefore, we decided that the Plan does not have to pay for the thiamine hcl injection coded J3411, the  
pyridoxine hcl injection coded J3415, and the vitamin b-12 cyanocobalamin injection coded J3420 provided on 
March 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on July 7, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you went to the hospital for 
COVID-19 testing but they did not provide the testing there. The Plan denied your request. The Plan says the 
copayment was applied 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.  
 
Review of the file shows that you received ER services on July 7, 2020. The records show that you were 
evaluated for complaints of chest pain and received a chest x-ray and electrocardiogram (EKG). You have been 
asked to pay a $90 copayment for these services. These services fall 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 (ER) services rendered on 
July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 4, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the laboratory services are not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 7, 
2019. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you disagree with the charges 
because nothing was done for you during the visit. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical center.  
 
You received a laryngoscopy on January 7, 2019. A laryngoscopy is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the allowed amount of $140.94. Please note, the provider 
cannot balance bill you any additional amount beyond the allowed amount.  
 
You have been asked to pay $140.94 for a laryngoscopy. A laryngoscopy falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical center 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 laryngoscopy provided on January 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora neuromuscular stimulator (E0745) provided on January 31, 2020.You asked the Plan to pay fora neuromuscular stimulator. You say that this was medically necessary.The Plan denied your request. The Plan says this was provided following an unsolicited outreach call.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a ruralcensus tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora neuromuscular stimulator (E0745) provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 27, 2020. 
 
You asked the Plan to pay for the laboratory 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation does not support that these services were performed with blood 
sampling. Blood specimen collection is by venipuncture, however, the specimen collected for the billed codes 
are not documented; therefore, the billed services cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 
provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on June 17, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this has already been paid. The Plan 
denied your request. The Plan says the correct copayment has 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $105 copayment for outpatient diagnostic tests/in-network/diagnostic procedures/outpatient 
hospital.  
 
The enrollee has been asked to pay $76.82 which is less than your copayment amount of $105 for an x-ray. An 
x-ray falls within the outpatient diagnostic tests/in-network/diagnostic procedures/outpatient hospital 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 waive the copayment for an x-ray provided by a 
participating provider on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the walker purchased on April 18, 2020. 
 
You asked the Plan to reimburse you for the walker. You say that you need the walker so the Plan should not 
deny it. The Plan denied your request. The Plan says the walker was not denied, the Medicare Fee Schedule 
amount was applied to your deductible. 
 
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 $500 deductible for covered services.  
 
The item or service you asked the Plan to pay for falls within the covered benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered 
services. This cost sharing is a contractual obligation that had not been met at the time the walker was received 
on April 18, 2020. Therefore, we decided that the Plan does not have to reimburse you for the walker 
purchased on April 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177) and the low osmolar contrast material (Q9967) provided on May 7, 
2020. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
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 advanced imaging services. Additionally, enrollees must pay a 20% coinsurance for other 
Medicare-covered Part B drugs.  
 
You have been asked to pay $177.40 ($175 copayment + $12 Plan allowable charge x 20% coinsurance=$2.40) 
for the advanced imaging service and the Medicare-covered Part B drug injection provided. 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 computed tomography (CT) scan of the abdomen and pelvis with 
contrast (74177) and the low osmolar contrast material (Q9967) provided on May 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 23, 2016. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the timely filing limit 
has expired. 
 
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 July 27, 2018. 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 on July 23, 2016.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional ambulance millage (A0888) provided. 
 
You asked the Plan to pay for additional ambulance millage. You say that this should be covered. The Plan 
denied your request. The Plan says transportation is covered only to the nearest facility. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulance transport is covered to the nearest 
appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt 
therapy) as well as the return transport. 
 
We looked at the file and Medicare rules. The record shows that you requested to be transported to a facility 
that was not the nearest appropriate facility. The Plan paid the portion of the millage that would have been used 
for transport to the nearest facility. Based on this information, we decided that Medicare rules for coverage of 
additional ambulance millage have not been met. Therefore, we decided that the Plan does not have to pay for 
additional ambulance millage (A0888) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordurable medical equipment (HCPCS E0745) provided to the enrollee on May 31, 2020.You asked the Planto pay forthe services. You say that payment is due immediately.The Plandenied your request. The Plansaysthere are no documented attempts to contact this enrollee's local physicianThe Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth servicesonly if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does notshow that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plandoes not haveto pay fordurable medical equipment (HCPCS E0745) provided to the enrollee on May 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 12, 2020 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. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 June 12, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93880) provided April 30, 
2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment was 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 $160 
copayment for Diagnostic Radiology.  
 
You have been asked to pay a $160 copayment for the duplex scan. The duplex scan falls within the Diagnostic 
Radiology 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 duplex scan (93880) 
provided April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
February 7, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the services rendered were 
medically necessary due to the nature of the patient's conditions. The Plan denied your request. The Plan says 
prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 chiropractic manipulative treatment (98941) 
provided on February 7, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this request is due to fall risks. 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 shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71250) provided on June 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 71250 is part 
of an edit pair with procedure code 71275. Procedure code 71275 is a column one code, and procedure code 
71250 is a column two code. Procedure code 71275 has been billed and paid for this date of service, which 
means that procedure code 71250 is not eligible for payment. Therefore, we decided that the Plan does not have 
to pay for the services (CPT 71250) provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this copayment. 
The Plan denied your request. The Plan says the correct copayment has 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 $250 
copayment for outpatient diagnostic tests/radiology services.  
 
You have been asked to pay $245.80 which is less than your copayment amount of $250 for a CT scan. A CT 
scan 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a CT scan provided by a participating provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 90834 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 90834 and 90853. Code 90834 is a column II code with a 
modifier indicator of 1 when billed with column I code 90853. Code 90834 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services rendered.