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

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says these services were 
not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342, 88360 and 88381 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
inpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for date of service February 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided from January 19, 2022, to 
June 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be 
reprocessed and paid. The Plan denied your request. The Plan says there is no referral letter from an in-network 
provider for the services in this case. The Plan says that there are in-network providers available. The Plan also 
says the services were not medically necessary. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 office visit (99214) provided from January 19, 2022, to June 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on June 16, 2022. 
 
You asked the Plan to pay for an office visit. You say that the enrollee received services on this date of service. 
The Plan denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for surgical 
procedures includes payment for postoperative visits, defined as follow-up visits during the postoperative 
period of the surgery that are related to recovery from the surgery. Modifier -24is used to report an unrelated 
evaluation and management service by same physician during a postoperative period. 
 
We looked at the file and Medicare rules. The office visit at issue was provided during the post-operative period of the spinal cord stimulator implantation surgery provided by the same provider on June 9, 2022, and 
was not billed with Modifier 24 to indicate it was an unrelated service. Based on this information, we decided 
that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does 
not have to pay for an office visit (99215) provided on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested Vertiflex procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed before coverage 
can be approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services (76770 and 93976) provided to the enrollee 
on March 29, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 76857 and 93976 and between 93976 and 76770. This PTP edit has a modifier indicator 
of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not  
billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim could not be paid due to an 
omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for testing services (76770 and 93976) provided to the enrollee 
on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve SSBCI services. You say that you require SSBCI services. The Plan denied 
your request. The Plan says the criteria for coverage for SSBCI services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI services have not been met. Specifically, your provider has indicated you do not require 
intensive care coordination. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefit for the chronically ill (SSBCI) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy (PT), specialist visit, 
and drug services rendered from July 19, 2022, to August 22, 2022. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
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 $30 
copayment for each Medicare-covered physical therapy visit, a $25 copayment for each Medicare-covered 
specialist visit, and a 20% coinsurance for Medicare Part B covered drugs. 
 Review of the file shows that you had five physical therapy visits from July 26, 2022, to August 16, 2022.  
You have been asked to pay a $30 copayment per date of service for these services, for a total of $150. This 
item/service falls within the Medicare-covered physical therapy visit benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you had two specialist office visits on July 19, 2022, and August 22, 2022. You have been 
asked to pay a $25 copayment per date of service for these services, for a total of $50. This item/service falls 
within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. 
 
The file shows that you had five injections from July 26, 2022, to August 16, 2022. You have been asked to 
pay a 20% coinsurance for these services, for a total of $183.02. This item/service falls within the Medicare-
covered Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. 
 
The total amount you have been asked to pay for these services is $383.02. 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 copayments for the physical therapy (PT), specialist visit, and drug services rendered from July 
19, 2022, to August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
November 15, 2021. 
 
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 are not payable as they were 
rendered by an ineligible provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were rendered 
by an acupuncturist who was not under the supervision of a physician, physicians assistant, nurse practitioner, 
or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture 
treatment (97810, 97811) provided on November 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided to 
the enrollee on June 5, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says if there is no transport, then there is no Medicare-covered service. 
 
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 June 5, 2022. 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 ambulance response and treatment, no transport 
provided to the enrollee on June 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on August 16, 2022, 
to August 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $275 
copayment per day, per stay: Days 1-6 for inpatient hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. The plan covers an unlimited number of days for an inpatient hospital 
stay. There was only one day. Therefore, results in the total cost sharing amount of $275. 
 
 
 
 You have been asked to pay a $275 copayment per day for inpatient hospital stay. This item/service falls within 
the Inpatient hospital 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 inpatient 
hospital stay on August 16, 2022, to August 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammography provided on June 
09, 2022. 
 
You asked the Plan to waive the copayment for diagnostic mammography. You say that you have had other 
mammograms that did not have a copay but this one does. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for diagnostic mammography. This item/service 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 diagnostic mammography provided on June 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided July 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the prescribing physician 
recommends an extended lifetime use of the equipment as they are diagnosed with chronic pain and 
compromised mobility without the option for surgical correction. The Plan denied your request. The Plan says 
evidence of misrepresented services. 
 
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 physician order for the supplies provided in this case. Specifically, the Plan 
made outreach to the provider's office and was informed that they do not have any notes with the request. There 
is no evidence to support the ordering provider indicated ordered the service. 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 electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 
(A4595) provided July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 24, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you feel you should not pay 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 $225 
copayment for in-network outpatient diagnostic tests/advanced imaging.  
 
You have been asked to pay a $225 copayment for CT scan. However, you are only being asked to pay $80 
which is less than the required amount. 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 computed 
tomography (CT) scan provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair you purchased on May 12, 2022. 
 
You asked the Plan to pay for the shower chair. You say that this chair is medically necessary as you are unable 
to stand in the shower.  This chair allows you to sit and clean yourself. The Plan denied your request. The Plan 
says this item is not covered for any reason. 
 
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 pay for the shower chair you purchased on May 12, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 2, 2020, to 
August 6, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says no medical records were 
provided to support the billing of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services have 
been met. Specifically, the Plan requested medical records from you on multiple occasions to be able to 
determine if the services were payable and billed correctly.  You have not provided these records, despite these 
multiple requests. Therefore, we decided that the Plan does not have to pay for inpatient hospital services 
provided from August 2, 2020, to August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service 
May 6, 2022. 
 You asked the Plan to pay for procedure codes 99152 and 99153. You say that you have provided medical 
documentation to support payment. The Plan denied your request. The Plan says codes 99152 and 99153 are 
bundled into payment for code 77290. 
 
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 99152 
and 99153 is a column II code to column I code 77290 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service May 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a triamcinolone injection provided on 
April 14, 2022. 
 
You asked the Plan to waive the coinsurance for a triamcinolone injection. You say that you already paid a 
copayment, and you shouldn't need to pay anything else. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $8.96, resulting 
in a coinsurance amount of $1.79 ($8.96 x 20% = $1.79). 
 
You have been asked to pay a $1.79 coinsurance for a triamcinolone injection. This item/service falls within 
the Medicare Part B prescription drugs 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 coinsurance 
for a triamcinolone injection provided on April 14, 2022.