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

We decided that the Plan does not have to pay for a telephone evaluation and management service (99442) provided on February 10, 2021.

You asked the Plan to pay for a telephone evaluation and management service. You say that this is supported in the records. The Plan denied your request. The Plan says this 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. 

In this case, the CPT Code Manual definition of code 99442 is telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion. 

We find that CPT code 99442 is not supported in the medical record. Specifically, the record shows that the enrollee had an office visit with the same provider on February 8, 2021. The billed code cannot be used for services originating from a related service in the previous 7 days. Based on this information, we decided that Medicare rules for coverage of a telephone evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for a telephone evaluation and management service (99442) provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from 
December 21, 2020, through January 15, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that 99072 was established to 
report additional practice expenses during a Public Health Emergency including supplies and additional clinical 
staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled 
services are not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not 
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials 
provided from December 21, 2020, through January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and hyperbaric oxygen therapy (HBOT) rendered to you on April 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. The file shows that the provider was not certified in the Medicare program for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the office visit and hyperbaric oxygen therapy (HBOT) rendered to you on April 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy performed on July 26, 
2021.

You asked the Plan to waive the copayment for the cystourethroscopy. You say that you feel that the procedure 
should be considered a diagnostic test subject to a 5% coinsurance. 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 surgery or other services performed at an outpatient hospital or ambulatory surgical center. 

You have been asked to pay a $250 copayment for the cystourethroscopy. This type of test is considered a 
surgical procedure. The cystourethroscopy 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 cystourethroscopy performed on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for implantation of nerve end into bone or muscle (list separately in addition to neuroma excision) (64787) excision of neuroma, major peripheral nerve, except sciatic (64784) provided September 1, 2021.

You asked the Plan to pay for the outpatient surgery services. You say that this 09/01/2021 surgery is an identical claim to 11/16/2020 and needs payment for services rendered. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for implantation of nerve end into bone or muscle (list separately in addition to neuroma excision) (64787) excision of neuroma, major peripheral nerve, except sciatic (64784) provided September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular profile (81404, 81479) provided on March 29, 2021.

You asked the Plan to pay for a hereditary cardiovascular profile. 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 Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular profile have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular profile (81404, 81479) provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021 to May 31, 
2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code.

We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on May 3, 2021 to May 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 4,
2021.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were
provided as part of an annual wellness exam so you should not be responsible for 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 $35
copayment for laboratory services.
The record shows that you received laboratory services on August 4, 2021. Laboratory services are not
included in annual wellness exams. Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment for laboratory services. Laboratory 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 August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (C8924), doppler 
echocardiography (93321), and doppler echocardiography color flow velocity mapping (93325) provided on 
January 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the services rendered could have been provided in 
network. The Plan also says that there is no authorization on file for the services that were rendered.

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 outpatient 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 transthoracic echocardiography (C8924), 
doppler echocardiography (93321), and doppler echocardiography color flow velocity mapping (93325) 
provided on January 12, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) provided on August 
18, 2021.

You asked the Plan to pay for MRA 70544. You say that you are appealing with records to support this level of 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
code 70544 has a procedure-to-procedure (PTP) edit of 1 with code 70551 so is not separately payable without 
an appropriate modifier.

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 MRA 
70544 is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA) provided on August 18, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composite (D2330) provided on July 26, 2021, and August 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay in full for the periodic oral evaluation, prophylaxis, and resin-based composite. You say that you would like these claims to be reprocessed for payment at the in-network rate because you were not advised that the provider is now OON. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance for each service, plus the difference between the billed amount and allowed amount because the services were received OON. Therefore, we decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composite (D2330) provided on July 26, 2021, and August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a preventive medicine visit provided on July 8, 2021.

You asked the Plan to pay for preventive medicine visit. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says that the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and authorization was not obtained.

The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from 
network providers. The enrollee's contract with the Plan says that the Plan includes a Point of Service (POS) 
option which covers certain out-of-network services, and that referrals are not required. The enrollee's contract 
with the Plan also says that the Plan covers one comprehensive preventive medicine evaluation and 
management visit per year.

We looked at the file and Medicare rules. This service is covered by the Plan. Although this provider is out-ofnetwork with the Plan, this Plan includes a Point of Service (POS) option that covers out-of-network services 
and the enrollee's contract with the plan does not clearly state that prior authorization is required for an out-ofnetwork preventive medicine exam. The Plan did not provide any other rationale or evidence to support this 
denial of payment. Based on this information, we decided that Medicare rules and the Plan's rules for coverage 
of preventive medicine visit have been met. Therefore, we decided that the Plan has to pay for a preventive 
medicine visit provided on July 8, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on June 1, 2021.

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay noncontract providers at the preferred provider rate when services are not available from preferred providers in the 
service area. You say that the in-network benefits should be honored, and the claim processed for payment. 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 services of a physical/occupational therapist 
billed as services incident to a physician/non-physician practitioner's service must meet all incident 
requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a 
physician assistant. As such, occupational therapy services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapist on June 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 1, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). 
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 April 8, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021.

You asked the Plan to pay for the laboratory services. You say that you only receive specimens from the patients referring physician to test and report findings. You say that the attached records support that the claim is not hospice related and the claim should be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided July 6, 2021.

You asked the Plan to pay for the office visit. You say that it was your understanding that this provider was in network and the services should be covered. The Plan representative said that the billing code or something similar was incorrect. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486, 87541, 
87581, 87640) provided August 11, 2020.

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 documentation does not support the billed services.

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 87496, 87498, 87631, 87798, 87486, 87541, 87581 and 87640 are not supported in the 
medical record. Specifically, the place of service listed on the claim (81, lab) does not match the place of 
service detailed in the records (31, nursing facility). 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 (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on June 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 laboratory services rendered by the out-of-network (OON) provider on 
June 12, 2021.