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

 
We decided that the Plan does not have to pay for a preparation of recipient site by excision (15004) and an 
adjacent tissue transfer (14061) provided on August 24, 2021. 
 
You asked the Plan to pay for a preparation of recipient site by excision and an adjacent tissue transfer. You 
say that you have provided documentation to support the services billed. The Plan denied your request. The 
Plan says the available records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 15004 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 
100 sq cm or 1% of body area of infants and children"; and the definition of code 14061 is "Adjacent tissue 
transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm." 
 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 a preparation of recipient site by excision and an adjacent 
tissue transfer. Our reviewer says that the CPT codes at issue do not meet criteria for reimbursement. Our 
reviewer found that the general guidance for code 14061 is that it is used for tissue transfer repair of wound 
(10.1 to 30.0 sq centimeters) of eyelids, nose, ears, and/or lips. The available documentation does not support 
the tissue transfer or rearrangement of 10.1 to 30.0 sq centimeters. Regarding code 15004, the available 
documentation does not support excision of open wounds, burn eschar, or scar (including subcutaneous 
tissues), or incisional release of scar contracture in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a preparation of recipient site by excision and an adjacent tissue transfer have 
not been met. Therefore, we decided that the Plan does not have to pay for a preparation of recipient site by 
excision (15004) and an adjacent tissue transfer (14061) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment and an office visit provided from  
July 26, 2021, through August 2, 2021. 
 
You asked the Plan to pay for acupuncture and an office visit. The Plan denied your request. The Plan says 
excluded from Medicare coverage is any service other than manual manipulation for the treatment of 
subluxation of the spine. All types of acupuncture including dry needling for any condition other than cLBP are 
non-covered by Medicare. A review of the enrollees Evidence of Coverage for 2021 does not document any 
enhanced chiropractic or acupuncture services to include coverage of these services for the documented 
diagnoses. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also say all types of acupuncture including 
dry needling for any condition other than cLBP (chronic Lower Back Pain) are non-covered by Medicare.  
The records show that the service at issue is not manual manipulation of the spine. The records also show that 
the acupuncture treatment does not meet the Medicare coverage criteria for cLBP. Therefore, we decided that 
the Plan does not have to pay for acupuncture treatment and an office visit provided from July 26, 2021, 
through August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
 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 an epidural injection provided on 
November 29, 2021 have been met. The Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided September 13, 
2021. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you should not have a 
copayment because your purchased items are considered diabetic supplies. The Plan denied your request. The 
Plan says coinsurance 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 Medicare-covered items with a total rental or purchase price of $500 or more of the Medicare 
allowable rate per item per month.  
 
  You have been asked to pay $224.88 for diabetic supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
September 13, 2021 Diabetic supplies $594.90 20% $118.98 
September 13, 2021 Diabetic supplies $529.52 20% $105.90 
Total    $224.88 
 
Diabetic supplies fall within the Durable medical equipment (DME) and related 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 diabetic supplies provided September 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
November 29, 2021, and December 9, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that you cannot afford 
the bills. 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for each ambulance transportation service, for a total of $500 
($250 copayment x 2 trips = $500). The ambulance transportation 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 copayments for ambulance transportation provided on 
November 29, 2021, and December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74018) provided December 7, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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. In this case, we have confirmed that code 74018 
has a bundled relationship with code74430. 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 radiology services (74018) provided December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microbiology culture and typing procedures (87150) 
infectious agent antigen detection by immunoassay technique (87324) provided September 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are legally obligated to process 
specimens it receives and therefore it must provide clinical laboratory services to insurance subscribers without 
prejudice. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for microbiology culture and typing procedures (87150) infectious agent 
antigen detection by immunoassay technique (87324) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anesthesia provided on November 1, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Anesthesia. 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 there isn't documentation showing 
these services were urgent or emergent. 
 
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 Anesthesia provided on November 1, 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 January 11, 2022, by an 
OON provider. 
  You asked the Plan to pay for the laboratory services. You say that you disagree with the denied claim due to 
missing prior-authorization and would like reconsideration on the claim. The Plan denied your request. The 
Plan says the rendering and referring providers are both OON providers and there was no referral from the 
enrollee's primary care provider or an approved 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 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 the laboratory services provided on January 11, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99212), the tangential 
biopsy of skin lesions (11102), and the supplies and materials, provided by the physician or other qualified 
health care professional over and above those usually included with an office visit or other services (99070) 
rendered by the out-of-network (OON) provider on January 13, 2022. 
 You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the items/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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 (99212), the tangential biopsy of 
skin lesions (11102), and the supplies and materials, provided by the physician or other qualified health care 
professional over and above those usually included with an office visit or other services (99070) rendered by 
the out-of-network (OON) provider on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on September 29, 
2021. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The genetic testing at issue was billed with 81455 and is not 
considered medically necessary. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (81455) provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 4, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was ordered by the treating 
physician, and you would like payment for the test. The Plan denied your request. The Plan says the rendering 
and referring providers are both OON providers and there was no approved 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 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 the laboratory services provided on January 4, 
2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiac catheterization procedure 
performed on December 13, 2021. 
 
You asked the Plan to waive the copayment for the catheterization. You say that you were informed that it 
would be covered since the provider is in-network. 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 $295 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a $295 copayment for the catheterization. The catheterization 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 cardiac 
catheterization procedure performed on December 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (92960) provided December 13, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another 
code 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. In this case, we have confirmed that code 92960 
is a column II code to column I code 99291. 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 emergency room services (92960) provided December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 23, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says the members 
primary insurance is with another carrier with an effective date January 25, 2019 with no term date. An EOB 
from the primary insurance payer is needed to process the claim under the member's Plan benefits. 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an EOB from the enrollees primary insurance carrier. As the secondary insurer, the Plan cannot be held 
responsible for the anesthesia services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for anesthesia services provided on  
November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for phlebotomy services (99195) provided January 7, 2022. 
 
You asked the Plan to pay for phlebotomy services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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. 
 
 
 
 
 
 
 We find that CPT code 99195 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule this service is considered an incident-to service when provided in the hospital setting. The claim 
was billed with place of service 22. The code is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of phlebotomy services have not been met. Therefore, we decided that the 
Plan does not have to pay for phlebotomy services (99195) provided January 7, 2022.