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

 
We decided that the Plan does not have to pay for the ureterolysis services provided on September 16, 2019. 
 
You asked the Plan to pay for the ureterolysis 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. 
 
In this case, the CPT Code Manual definition of code 50715 is ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis. 
 
We find that CPT code 50715 is not supported in the medical record. Specifically, this code was not billed with 
the required anatomical modifier (LT- left side, RT- right side, or 50- bilateral). Based on this information, we 
decided that Medicare rules for coverage of the ureterolysis services have not been met. Therefore, we decided 
that the Plan does not have to pay for the ureterolysis services provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear (V2025, V2781, V2745, V2750) purchased from an 
out-of-network provider on October 4, 2019. 
 
You asked the Plan to pay for eyewear. You say that you were fully covered at this time. The Plan denied your 
request. The Plan says eyewear is only covered in-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a doctor in the vision network. 
 
We looked at the file and the Plan's rules. This eyewear was not provided by an in-networBased on this 
information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided 
that the Plan does not have to pay for eyewear (V2025, V2781, V2745, V2750) purchased from an out-of-
network provider on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of heart-lung machine (99190) 
provided April 15, 2020. 
 
You asked the Plan to pay for assembly and operation of heart-lung machine. You say that these charges are for 
the perfusionist that setup and operated the heart-lung machine. The perfusionist is required to be in the 
operating room during the length of the procedure. The Plan denied your request. The Plan says payment for 
this service would be included in the part-A DRG payment to the facility. Payment for this service is the 
responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. The enrollee was an inpatient, therefore all services provided to the enrollee will be paid under the 
global facility claim. Payment for the perfusionist service would have been included under the facility claim. 
Payment to the perfusionist for this service is the responsibility of the facility or hospital.  Based on this 
information, we decided that Medicare rules for coverage of assembly and operation of heart-lung machine 
have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of 
heart-lung machine (99190) provided April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 31, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
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 laboratory services provided 
to the enrollee on January 31, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
provided from October 1, 2019 through October 2, 2019. 
 
You asked the Plan to waive the copayment for the ER services. You say that you believed the enrollee was 
admitted to the hospital, so no copayment for the ER visit should be due. The Plan denied your request. The 
Plan says you were charged this copayment 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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care.  This copayment is waived if you are admitted to the hospital.  
 
In this case, the Plan has charged a $90 copayment for the ER services. The records show that the enrollee was 
not admitted to the hospital, but instead was kept in observation.  Observation status is not considered a 
hospital admission. 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. 
Please note that this decision is limited only to the ER copayment that was charged.  We understand that you 
had other cost sharing and deductible issues that were addressed in previous cases.  Therefore, we decided that 
the Plan does not have to waive the copayment for the emergency room (ER) services provided from October 
1, 2019 through October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14301, 14302, 
14001) provided July 29, 2019. 
 
You asked the Plan to pay for adjacent tissue transfer or rearrangement. You say that you would like 
reconsideration based on the medical records provided. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
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 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 adjacent tissue transfer or rearrangement. 
Our reviewer says that the medical records do not support the codes billed. Our physician reviewer found the 
medical records provided does not include documentation of an adjacent tissue transfer or rearrangement. The 
medical records indicate that wide undermining and advancement of tissue was performed which does not 
constitute an adjacent tissue transfer as described in the services at issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adjacent tissue transfer or rearrangement have not been met. Therefore, we 
decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14301, 14302, 14001) 
provided July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 25, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this provider is 
out-of-network with the Plan and the ordering physician is also out-of-network with the Plan. 
 
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 medical services provided on April 25, 2019 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump supplies rendered on March 23, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the infusion pump supplies rendered on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of subcutaneous reservoir or pump services 
coded 62365 provided on March 13, 2020. 
 
You asked the Plan to pay for the removal of subcutaneous reservoir or pump 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. 
 
In this case, the CPT Code Manual definition of code 62365 is removal of subcutaneous reservoir or pump, 
previously implanted for intrathecal or epidural infusion. 
 
We find that CPT code 62365 is not supported in the medical record. Specifically, this service was billed with 
an incorrect place of service. This code is assigned a non-facility NA indicator. Based on this information, we 
decided that Medicare rules for coverage of the removal of subcutaneous reservoir or pump services have not 
been met. Therefore, we decided that the Plan does not have to pay for the removal of subcutaneous reservoir 
or pump services coded 62365 provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that out-of-network services require prior authorization. 
 
The requested provider in this case is not a network provider with the Plan. 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 to the enrollee by an out-of-
network provider on April 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided May 
21, 2019. 
 
You asked the Plan to pay for the 3D rendering with interpretation. You say that you feel the diagnosis used 
does meet the medical necessity for the service provided. Please reprocess this claim for payment. The Plan 
denied your request. The Plan says when an imaging radiologic study is performed and 3D-rendering with 
interpretation is done, reimbursement will be considered as part of the primary radiologic procedure 
 
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 the 3D 
rendering with interpretation has a bundled relationship with the primary imaging procedure and cannot be paid 
as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) 
provided May 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to correct the copayments for physician visits at an assisted living facility (99335 
and 99336) and a Medicare-covered home health recertification (G0179) from September 20, 2019, to March 
31, 2020. 
 
You asked the Plan to correct the copayments for physician visits at an assisted living facility and a Medicare-
covered home health recertification. You say that the Plan is incorrectly charging the copayment for a specialist 
visit. The Plan denied your request. The Plan says that the correct copayments were 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 says that enrollees must pay a 
$5 copayment for each covered Primary Care Provider office visit.  
 
The Plan says the enrollee must pay a $40 copayment for physician visits at an assisted living facility and a 
Medicare-covered home health recertification. The provider in question, however, is an internal-medicine 
practitioner, not a specialist. Based on the plan contract, the enrollee cannot be asked to pay more than a $5 
copayment for physician visits at an assisted living facility and a Medicare-covered home health recertification. 
Therefore, we decided that the Plan has to correct the copayments for physician visits at an assisted living 
facility (99335 and 99336) and a Medicare-covered home health recertification (G0179) from September 20, 
2019, to March 31, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of heart-lung machine (99190) 
on March 6, 2020. 
 
You asked the Plan to pay for the assembly and operation of heart-lung machine. You say that these charges 
are for the perfusionist that setup and operated the heart-lung machine. The perfusionist is required to be in the 
operating room during the length of the procedure. The Plan denied your request. The Plan says payment for 
this service would be included in the part-A DRG payment to the facility. Payment for this service is the 
responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. The enrollee was an inpatient, therefore all services provided to the enrollee will be paid under the 
global facility claim. Payment for the perfusionist service would have been included under the facility claim. 
Payment to the perfusionist for this service is the responsibility of the facility or hospital. Based on this 
information, we decided that Medicare rules for coverage of assembly and operation of heart-lung machine 
have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of 
heart-lung machine (99190) on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on the insertion of a spine fixation 
device (22840) provided on  October 2, 2019. 
 
You asked the Plan to pay for surgical assistant services on the insertion of a spine fixation device. You say 
that this should be covered. The Plan denied your request. The Plan says this code is not supported. 
 
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 22840 is posterior non-segmental instrumentation (eg, 
Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, 
sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure). 
 
We find that CPT code 22840 is not supported in the medical record. Specifically, this procedure is not 
documented in the medical records and was not billed by the primary surgeon. Based on this information, we 
decided that Medicare rules for coverage of the insertion of a spine fixation device have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical assistant services on the insertion of a 
spine fixation device (22840) provided on  October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80061, 82607, 83735, 82746, 
82627, 82670, 83001, 84270, 84402, 84403, 84146, 84144, 84481, 84439, 84443, 83090, 80053 and 36415 
provided on December 10, 2019. 
 
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 80061, 82607, 83735, 82746, 82627, 82670, 83001, 84270, 84402, 84403, 84146, 
84144, 84481, 84439, 84443, 83090, 80053 and 36415 are not supported in the medical record. Specifically, 
the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen 
was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place 
of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen 
was obtained in an office setting, place of service 11. 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 80061, 82607, 83735, 82746, 82627, 82670, 83001, 84270, 
84402, 84403, 84146, 84144, 84481, 84439, 84443, 83090, 80053 and 36415 provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), electrocardiogram (93000), annual 
depression screening (G0444), routine venipuncture (36415), initial comprehensive preventive medicine 
evaluation (99387), and the laboratory services (85025, 80053, 80061, 83036) rendered by the out of network 
(OON) provider on March 24, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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. 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 office visit (99214), electrocardiogram (93000), annual depression screening 
(G0444), routine venipuncture (36415), initial comprehensive preventive medicine evaluation (99387), and the 
laboratory services (85025, 80053, 80061, 83036) rendered by the out of network (OON) provider on  
March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the middle spinal canal 
(72146) performed on May 18, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of the middle spinal canal. You say that you 
needed a second MRI due to technician error and should not have to pay again. 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 $150 
copayment for advanced imaging services.  
 
You have been asked to pay a $150 copayment for an MRI scan of the middle spinal canal. An MRI scan of the 
middle spinal canal falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an MRI scan of the middle spinal canal (72146) 
performed on May 18, 2020.  
 
Your complaint about the MRI technician's error 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.