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

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on  
September 29, 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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81000, 82570, 84480) provided on 
March 15, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says these codes are 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 CPT code. In this case, we have confirmed that codes 
81000 and 82570 are column II codes to column I code 80307, and 84480 is a column II code to column I code 
84481. This claim has not been billed with appropriate modifiers to bypass the edits. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for laboratory services (81000, 82570, 84480) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis (20610) provided on October 
26, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that the services should be covered 
as you were not made aware of the copayment beforehand. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  The record indicates that you received arthrocentesis at an outpatient hospital facility on October 26, 2021. 
Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $260 
copayment. 
 
You have been asked to pay a $260 copayment for the arthrocentesis. Arthrocentesis 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 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 arthrocentesis (20610) provided on October 26, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
August 9, 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 there is no additional documentation supporting additional studies which were billed and remain 
denied. 
 
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 the denied codes is: 
 
CPT 72070: 
 
Radiologic examination, spine; thoracic, 2 views 
 
CPT 72100: 
 
Radiologic examination, spine, lumbosacral; 2 or 3 views 
 
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 while there are two reports of both the 
thoracic and lumbar spine series of 8/9/21, they are duplicates. Only one exam each was performed. Claims 
have been processed and no additional payment should be made. 
 
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 additional imaging services provided to the enrollee on August 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for spinal canal injections provided on July 
12, 2021, and November 17, 2021. 
 
You asked the Plan to waive the copayments for spinal canal injections. You say that you cannot afford the 
charges. 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 $200 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You received spinal canal injections at an ambulatory surgical center on July 12, 2021, and November 17, 2021. Spinal canal injections are considered outpatient surgical procedures. Therefore, you are responsible to 
pay a $200 copayment per each visit. The total amount you owe is: $200 (copayment) x 2 (spinal canal 
injections) = $400.  
 
You have been asked to pay the total copayment amount of $400 for spinal canal injections. Spinal canal 
injections fall 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 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 spinal 
canal injections provided on July 12, 2021, and November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 5, 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 
member and 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 March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (cutaneous melanoma), gene expression 
profiling (81529) rendered by the out-of-network (OON) provider on September 13, 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 (cutaneous melanoma), gene expression profiling (81529) rendered by 
the out-of-network (OON) provider on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 28, 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 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 office visit (99202) provided on 
January 28, 2021. have 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 January 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on July 
28, 2021. 
 
You asked the Plan to pay for nursing facility care supervision. You say that this service was provided in good 
faith and meets professionally recognized standards of healthcare. The Plan denied your request. The Plan says 
this service has a status indicator of "B", which means that payment for this service is always bundled into 
payment for another 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 99379 has a status code of B  Bundled Code. Payment for covered services are 
always bundled into payment for other services not specified. If RVUs are shown, they are not used for 
Medicare payment. If these services are covered, payment for them is subsumed by the payment for the 
services to which they are incident. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules for coverage of nursing facility care supervision have not been met. Therefore, we decided that the Plan does 
not have to pay for nursing facility care supervision (99379) provided on July 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on July 
28, 2021. 
 
You asked the Plan to pay for nursing facility care supervision. You say that this service was provided in good 
faith and meets professionally recognized standards of healthcare. The Plan denied your request. The Plan says 
this service has a status indicator of "B", which means that payment for this service is always bundled into 
payment for another 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 99379 has a status code of B  Bundled Code. Payment for covered services are 
always bundled into payment for other services not specified. If Relative Value Units (RVUs) are shown, they 
are not used for Medicare payment. If these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules for coverage of nursing facility care supervision have not been met. Therefore, we decided that the Plan does 
not have to pay for nursing facility care supervision (99379) provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a puncture aspiration of breast cyst (19000) 
provided on October 22, 2021. 
 
You asked the Plan to waive the copayment for a puncture aspiration of breast cyst. You say that you paid a 
$35 copayment and the rest should have been paid by the Plan. 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $250 copayment for a puncture aspiration of breast cyst. A puncture aspiration of breast cyst falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a puncture aspiration of breast cyst (19000) provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on March 25, 2020. 
 
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 office visit (99214) rendered by the out-of-
network (OON) provider on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on April 20, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that did not know the Plan had its own 
specialist for hearing aids. The Plan denied your request. The Plan says members must use the Plans hearing 
provider to use this benefit. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. 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 reimburse you for hearing aids 
provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
27, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that your vitals were taken, and 
the doctor glanced at your wound before instructing you to go to the emergency room. You also say you should 
not have to pay for this visit due to the poor care you received. 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 $45 
copayment for urgent care services at an urgent care center.  
 
 The records show you received urgent care services on November 27, 2021. You have been asked to pay a $45 
copayment for an urgent care visit. An urgent care visit falls within the Urgent Care 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 an urgent care visit provided on November 27, 2021.  
 
Your complaint about receiving poor care at the urgent care center 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Fluciclovine f-18 (code A9588) provided 
on September 24, 2021. 
 
You asked the Plan to waive the coinsurance for Fluciclovine f-18 (code A9588). You say that you already paid 
the copayment for the PET scan so this coinsurance charge should be waived. The Plan denied your request. 
The Plan says the coinsurance amount charged 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 20% 
coinsurance for each Medicare-covered medical supply.  
 
You have been asked to pay 20% coinsurance resulting in a $1,094.40 charge, ($5,472.00 x 20%), for 
fluciclovine f-18 (code A9588). Fluciclovine f-18 (code A9588) 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 coinsurance 
for Fluciclovine f-18 (code A9588) provided on September 24, 2021.  
 
Please note that this decision is only regarding Fluciclovine f-18 (code A9588) provided on September 24, 
2021. Please contact the Plan regarding appeals for any other items or services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 8, 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 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 8, 2021.