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

 
We decided that the Plan does not have to pay for Immunohistochemistry or immunocytochemistry, per 
specimen (88341) provided August 11, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that please see attached documentation showing 
all services were performed and reconsider for payment. The Plan denied your request. The Plan says this is an 
adjustment for an overpayment on a previously processed claim. 
 
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 88341 is Immunohistochemistry or 
Immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)  
 
We find that CPT code 88341 is not supported in the medical record. Specifically, the records show that 
payments was issued for CPT Code 88341 for this same date of service on checks dated 09/24/2020 and on 
check dated 09/29/2020. 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 
Immunohistochemistry or immunocytochemistry, per specimen (88341) provided August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 29, 2021. 
 
You asked the Plan to pay for the blood smear 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 with an inappropriate place of 
service. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 8. This indicator identifies the professional component of clinical 
laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear 
for hospital inpatient. This code was billed with place of service 22 (outpatient hospital), which is considered 
an inappropriate place of service. This means this claim was billed incorrectly. Based on this information, we 
decided that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided 
that the Plan does not have to pay for the blood smear services coded 85060 provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on January 
5, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you never saw the doctor so 
this visit should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for office visits to specialists.  
 
You have been asked to pay $50 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner services, including doctors office visits 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 specialist office visit provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 24, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that this was part of your yearly 
physical. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 up to a 
$10 copayment for lab services.  
 
The file shows that you were not billed for the routine lab services. However, other lab services that are not 
routine were also billed, and are subject to the copayment. Therefore, you have been asked to pay a $10 
copayment for the lab services. The lab services fall 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 laboratory 
services provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a naturopathic office visit provided on March 17, 2022. 
 
You asked the Plan to pay for the naturopathic office visit. You say that this service should be covered. The 
Plan denied your request. The Plan says a naturopathic office visit is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for a naturopathic office visit provided on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82306, 84153 86141 
provided August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that all of these tests are medically necessary 
and should have been given a billing code by your primary care provider. The Plan denied your request. The 
Plan says these services are not covered by the Plan. 
 
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 laboratory services coded as 
82306, 84153 86141 provided August 4, 2021. have been met. the records show that the Plan made 7 outreach 
attempts to the provider to obtain clinical documentation without success. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 82306, 84153 86141 provided August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on February 4, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you also had a CT scan that day 
that was processed differently. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 $170 
copayment for each radiological diagnostic service, including ultrasounds.  
 
You have been asked to pay $92.77, which is less than the $170 copayment for the ultrasound. The ultrasound 
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 ultrasound of the head and neck provided on February 4, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on February 
12, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for 
this date of service. 
 
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 February 5, 2022. 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 subsequent 
hospital care services provided on February 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93971) performed September 8, 2021. 
 
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 code 93971 is not supported in the medical record. Specifically, per Local Coverage Article, 
Billing and Coding: Non-Invasive Evaluation of Extremity Veins (LCA A57125), the diagnosis codes billed 
are not valid for the procedure performed (G5711, G9389, E079, and E119). Based on this information, we 
decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the 
Plan does not have to pay for a duplex scan (93971) performed September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 83970) provided 
September 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the lab services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82728, 83540, 83550, 83970) provided September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for eye exam, imaging injection provided on 
January 7, 2022. 
 
You asked the Plan to waive the cost share for eye exam, ophthalmic imaging, and injection. You say that this 
charge should be covered. The Plan denied your request. The Plan says the cost share applied is correct. 
 
 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 $48 
copayment for eye exam, $75 copayment for ophthalmic imaging and 20% coinsurance for the injection. 
 
You have been asked to pay a total of $442.18 for the eye exam, ophthalmic imaging, and injection. The 
injection falls within the Medicare Part B prescription drugs benefit category. The ophthalmic imaging falls 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The eye exam 
falls within the Vision 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 cost share for eye exam, 
imaging injection provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 20, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2021. 
 
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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the enrollees Family Medicine Physician did not order the cardiovascular genetic 
testing for the enrollee. The documentation shows that the enrollee has not seen this provider since June 2020. 
This means the laboratory test at issue in this appeal coded 81286, 81413, 81414, 81442, and 81479 were 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.  
 
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 81400 is a column II code to column I code 
81413. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 19, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 15, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says 
Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services 
were provided. 
 
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 an emergency department visit was not filed until March 16, 2022. 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 an emergency department visit provided on  
May 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (51798) provided August 31, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
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 51798 has a bundled relationship with code 76770. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an ultrasound (51798) provided August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular 
supports, adjustable (L0180) provided February 7, 2022. 
 
You asked the Plan to pay for the cervical orthosis. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the request for this item exceeds the 
reasonable useful lifetime (RUL) limits.  
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The records show that L0180 was processed and paid 05/09/2020. The reasonable useful lifetime of DME or 
prosthetic and orthotic devices is determined through program instructions. In the absence of program 
instructions, carriers may determine the reasonable useful lifetime of equipment but in no case can it be less 
than 5 years. Therefore, we decided that the Plan does not have to pay for the cervical, multiple post collar, 
occipital/mandibular supports, adjustable (L0180) provided February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86334, 86333) provided December 23, 2021 to 
December 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 86334, & 86333 are not supported in the medical record. Specifically, these codes are 
obsolete and no longer valid for payment. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (86334, 86333) provided December 23, 2021 to December 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cryoablation of malignant breast tumors (0581T) 
provided December 7, 2021. 
 
You asked the Plan to pay for the ablation procedure. You say that please review the following medical records 
to reconsider denial code 0581T for medical necessity. You believe these services were appropriate based on 
past medical history. The Plan denied your request. The Plan says this service is 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. Codes with a MUE value of 0 (zero) are invalid, 
not covered, bundled, not separately payable, statutorily excluded, or not reasonable and necessary in accordance with Medicare regulations or guidance. In this case, we have confirmed that code 0581T has a 
medical unlikely edit (MUE) value of zero (0) and is therefore not eligible for reimbursement. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the cryoablation of malignant breast tumors (0581T) provided December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided May 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient information was provided to support the claim. 
 
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. Additional clinical records were requested by the plan to support this 
service. None were provided. Based on this information, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage of lab services (81455) provided May 17, 2021. have been 
met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 4, 
2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this charge should be 
covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $290 
copayment for Ambulance services.  
 
You have been asked to pay $290 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2522) provided on February 16, 2022. 
 
  You asked the Plan to pay for the contact lenses. You say that you have undergone treatment for Cervical and 
Small Cell Lung Cancer in the past year and your eyes have made a change. You also say that you would like 
the Plan to cover the new contact lens. The Plan denied your request. The Plan says glasses or contact lenses 
are only allowed once per two calendar years. 
 
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 1 pair of eyeglass frames or 1 pair of contact lenses (or 2 six packs) every two 
calendar years. 
 
We looked at the file and the Plan's rules. The record shows that you received contact lenses on February 2, 
2021 and your contact lens benefit has been exhausted. Based on this information, we decided that the Plan's 
rules for coverage of the contact lens have not been met. Therefore, we decided that the Plan does not have to 
pay for the contact lenses (V2522) provided on February 16, 2022.