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

 
We decided that the Plan does not have to pay for fluoroscopic guidance (procedure code 77002) provided to 
the enrollee on March 24, 2021. 
 
 
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 the denied code remains 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 77002 is :Fluoroscopic guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure)." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the record indicates that the enrollee 
has wrist pain due to Dupuytren's disease and underwent a procedure. The record provided does not describe the use of fluoroscopy. The elements of the coverage criteria are not satisfied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for fluoroscopic guidance (procedure code 77002) provided to the enrollee on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on October 11, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you went to a provider in your Plan's medical 
network and these services should be covered. The Plan denied your request. The Plan says these hearing aids 
were not purchased through the Plans designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the Plans specified hearing vendor.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the routine vendor network as 
specified by the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) 
provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report (92134) rendered by the out-of-network (OON) provider on 
October 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report (92134) rendered by the out-of-network (OON) provider on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 12, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation 
with initiation of a diagnostic and treatment program (92004), the fundus photography with interpretation and 
report (92250), and the lenses (V2200) rendered by the out-of-network (OON) provider on July 15, 2021. 
 
You asked the Plan to pay for this item/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 item/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 had network providers available 
who could have provided the item/services at issue in this appeal. The Plan did not pre-approve the 
item/services at issue. We found no exception that would require the Plan to pay for this item/services. 
Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and 
evaluation with initiation of a diagnostic and treatment program (92004), the fundus photography with 
interpretation and report (92250), and the lenses (V2200) rendered by the out-of-network (OON) provider on 
July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on July 22, 2021. 
 
You asked the Plan to pay for the ambulance response without transport. You say that you were told it would 
be expensive to take the ambulance to the hospital, and you were encouraged to have a family member drive 
you. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When there 
is no transportation provided, there is no payable 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 July 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport (A0998) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Subsequent hospital care, per day, for the evaluation and 
management of a patient (99232-57) provided on August 31, 2021. 
 
You asked the Plan to pay for code 99232-57. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The Global Surgery Package includes follow-up evaluation and management visits during the postoperative period of the surgery that are related to recovery from the surgery. 
In this case, code 99232 was bundled as part of the global surgical package of major procedure code 61313. 
Review of the records indicates that the service performed was unrelated to the major procedure performed on 
July 25, 2021. However, code 99232 was not billed with the appropriate "24" modifier indicating that the 
denied service was unrelated and rendered during the post-operative period of a global procedure. Therefore, 
we decided that the Plan does not have to pay for the Subsequent hospital care, per day, for the evaluation and 
management of a patient (99232-57) provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery you had at an outpatient 
hospital facility on November 3, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you had hip surgery in 
2017 and you only paid $360 for an overnight stay.  You said that you shouldn't have to pay more for a shorter 
procedure that did not require an overnight stay. The Plan denied your request. The Plan says you were charged 
this coinsurance 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 20% 
coinsurance for outpatient surgery.  
 
You have been asked to pay 20% coinsurance for the outpatient surgery. This cost sharing applies regardless of how the costs compare to inpatient hospital services. 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 
outpatient surgery you had at an outpatient hospital facility on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a subcutaneous tissue debridement 
(11042) provided on November 16 to December 14, 2021. 
 
You asked the Plan to waive the copayments for a subcutaneous tissue debridement. You say that you were 
never told you would be responsible for part of the bill for the services at issue. The Plan denied your request. 
The Plan says 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). Your contract with the Plan clearly says that you must pay a $350 
copayment for each Medicare-covered outpatient hospital facility surgery.  
 
You have been asked to pay a $341.32 copayment for each date of service for a subcutaneous tissue 
debridement. A subcutaneous tissue debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you 
have been asked to pay less than or equal to the full and 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 copayments for a subcutaneous tissue debridement (11042) 
provided on November 16 to December 14, 2021.  
 
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility 
from representatives of the provider is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 1, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (urothelial), gene expression profiling (0013M) 
rendered by the out-of-network (OON) provider on August 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the oncology (urothelial), gene expression profiling (0013M) rendered by the out-of-
network (OON) provider on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for myocardial perfusion imaging and a stress 
test and does not have to waive the coinsurance for medical supplies and a Medicare Part B drug provided on 
September 4, 2021. 
 
You asked the Plan to waive the copayments for myocardial perfusion imaging and a stress test and to waive 
the coinsurance for medical supplies and a Medicare Part B drug. You say that you disagree with the charges 
and feel that the Plan should pay more. 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 $155 
copayment for nuclear studies, a $30 copayment for non-radiological diagnostic services, and 20% coinsurance 
for medical supplies and Medicare Part B prescription drugs. 
 
You received myocardial perfusion imaging, a stress test, medical supplies and a Medicare Part B drug 
provided on September 4, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. 
Please see the chart below.  
 
Date of Service  Service Allowed Amount Amount You Owe 
9/4/2021 Myocardial Perfusion 
Imaging 
$422.28 $155 
9/4/2021 Stress Test $53.09 $30 
9/4/2021 Medical Supplies $118 $23.60 
9/4/2021 Medicare Part B Drug $237.24 $47.45 
 
The total amount you owe is: $256.05. 
 
You have been asked to pay the total amount of $256.05 for myocardial perfusion imaging, a stress test, 
medical supplies and a Medicare Part B drug. Myocardial perfusion imaging, a stress test and medical supplies 
fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare 
Part B drug 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 copayments for myocardial perfusion imaging and a stress test and does not have to waive the 
coinsurance for medical supplies and a Medicare Part B drug provided on September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 3, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 ultrasound of the abdomen (76705) provided on November 
10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the joint aspiration procedure you had on 
October 18, 2021, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the joint aspiration procedure. You say that you do not 
understand why there is a copayment requirement for the services provided. The Plan denied your request. The 
Plan says the facility where you received these services is considered an outpatient hospital facility.  The Plan 
says that because the allowed amount for the procedure you had ($260.28) is less than your copayment 
obligation, you are responsible for the full allowed 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 $325 
copayment for surgery or other services at an outpatient hospital facility.  
 You have been asked to pay a $325 copayment for joint aspiration procedure. The joint aspiration procedure 
falls within the surgery or other services at an outpatient hospital facility 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 joint aspiration procedure you had on October 18, 2021, at an 
outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the routine 
venipuncture (36415), and the laboratory services (82784, 85007, 85027) rendered by the out-of-network 
(OON) provider on October 12, 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 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 had network providers available 
who could have provided 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 hospital outpatient clinic visit (G0463), the routine venipuncture (36415), and 
the laboratory services (82784, 85007, 85027) rendered by the out-of-network (OON) provider on October 12, 
2021.