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

 
We decided that the Plan does not have to pay for allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (CPT code 20930) and autograft for spine surgery only (includes harvesting the 
graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (CPT code 20936) 
provided on September 2, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT code(s): 20930 and 20936, 
which has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into 
payment for other services not specified and no separate payment is made per Medicare. Therefore, we decided 
that the Plan does not have to pay for allograft, morselized, or placement of osteopromotive material, for spine 
surgery only (CPT code 20930) and autograft for spine surgery only (includes harvesting the graft); local (eg, 
ribs, spinous process, or laminar fragments) obtained from same incision (CPT code 20936) provided on 
September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81235, 
81292, 81301, 81321) provided on July 21, 2021. 
 
You asked the Plan to pay for the molecular pathology testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the molecular pathology testing have not been met. Medicare 
denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code 
must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the molecular 
pathology testing (CPT code(s): 81206, 81235, 81292, 81301, 81321) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy techniques (eg, mobilization/ manipulation, 
manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (CPT code 97140) and 
therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (CPT code 
97112) provided from October 5, 2021, through October 26, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97140 and 98940 are not supported in the medical record. Specifically, CPT code 
97140 remains not supported. This code is included in CPT code 98940; therefore, it cannot be separately 
reimbursed. The medical records received do not support that the procedure or service was distinct or 
independent from other services performed; therefore, the use of the GP and XS modifiers are not supported. 
Per Medicare guidelines, CPT code 97140 is not covered when billed by a Chiropractor. CPT code 97112 
remains not supported. This code is included in CPT code 98940; therefore, it cannot be separately reimbursed. 
The medical records received do not support that the procedure or service was distinct or independent from 
other services performed; therefore, the use of the GP and XS modifiers are not supported. Per Medicare 
guidelines, CPT code 97112 is not covered when billed by a Chiropractor. 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 manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic 
drainage, manual traction), 1 or more regions, each 15 minutes (CPT code 97140) and therapeutic procedure, 1 
or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities (CPT code 97112) provided from 
October 5, 2021, through October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services and outpatient hospital 
services provided on December 9, 2021, and December 22, 2021. 
 
You asked the Plan to waive the coinsurance for the laboratory services and outpatient hospital services. You 
say that the services should be covered as you disagree with the charges. The Plan denied your request. The 
Plan says the coinsurance 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 50% 
coinsurance for out-of-network outpatient hospital services.  
 
 
  You have been asked to pay a 50% coinsurance for the laboratory services and outpatient hospital services 
(total allowed is $453.88 x 50% = 226.94). Laboratory services and Outpatient hospital services fall within the 
Outpatient hospital 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 coinsurance for laboratory 
services and outpatient hospital services provided on December 9, 2021, and December 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 30, 2021, to August 2, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover custodial services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not qualify for SNF coverage. 
The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled 
therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
We looked at this physician'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 skilled nursing facility (SNF) services provided to the enrollee from July 30, 2021, to August 2, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206 and 81292) 
provided on July 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered 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. 
 
If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so on CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 81206 and 81292) provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp cap - indirect (excluding final restoration) (D3120) 
and resin-based composite - three surfaces, posterior (D2393) for tooth 2 provided December 9, 2021. 
 
You asked the Plan to pay for the pulp cap and multi-surface white filling. You say that your benefits do not 
discriminate against the material used for a filling. The Plan denied your request. The Plan says the pulp cap is 
not a covered service, and the filling has processed correctly according to your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers multi-surface 
white fillings on back teeth as silver fillings and you are responsible for the difference in cost.   
We looked at the file and Medicare rules. In this case you had a multi-surface white filling on a back tooth. The 
Plan correctly processed this as a silver filling. You are responsible for 50% coinsurance for the silver filling 
plus the difference between the cost of a silver filling and the cost charged for the multi-surface white filling. 
Though the Plan offers dental benefits in excess of Medicare coverage, the pulp cap is not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the pulp cap - indirect (excluding final 
restoration) (D3120) and resin-based composite - three surfaces, posterior (D2393) for tooth 2 provided 
December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. 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 $35 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit. Specialist office visits fall within the 
Outpatient hospital 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 a specialist 
office visit provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 
24-hour facility, in addition to basic service (CPT code 99053) provided on September 6, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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.  
CPT code 99053, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always 
bundled into payment for other services not specified and no separate payment is made per Medicare. 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 the service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (CPT code 99053) provided on September 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0999) provided on 
November 22, 2021. 
 You asked the Plan to pay for the paramedic intercept 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 
provided do not meet Medicare criteria for payment in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services (A0999) provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON office visit services. You say that no other cardiologists from the 
network could perform the procedure needed. You say that yo udo not have a good quality of life at this 
moment and are not functioning well. The Plan denied your request. The Plan says they have confirmed there 
are at least 4 network thoracic surgeons in the enrollee's service area that specialize in the procedure being 
requested. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport (A0427) provided on November 27, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $300 
copayment per one-way trip by ground or air ambulance.  
 
You have been asked to pay a $300 copayment for the one-way ground ambulance trip provided. 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 ambulance service, advanced life support, 
emergency transport (A0427) provided on November 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a core build-up (D2950) provided by a 
participating provider on December 16, 2021. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you should not be penalized for 
incompetency and incorrect information given by the Plan's representative. The Plan denied your request. The 
Plan says D2740 and D2950 are not covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740), and a core build-up (D2950) provided by a participating provider on December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from May 4, 2021, through May 
13, 2021, at DRG 521. 
 
You asked the Plan to pay for inpatient services at DRG 521. You say that the diagnosis code is supported by 
the physician's documentation and in the information in the medical records. You say that with careful review 
of the medical records, the claim should be overturned. The Plan denied your request. The Plan says the 
determination to remove diagnosis code G93.41 and DRG 521 is upheld as DRG 522 is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with DRG 521 with diagnosis code, G93.41, defined as metabolic 
encephalopathy. We asked our physician reviewer 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 inpatient services at DRG 
521. Our reviewer says that the documentation does not support diagnosis code G93.41. Our physician 
reviewer found the correspondence stated the electroencephalogram (EEG) reported encephalopathy, however 
the EEG results report noted mild encephalopathy of toxic metabolic or degenerative etiology. The provider did 
not support the diagnosis of encephalopathy in the list of active problems with an assessment and plan to 
address the diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from May 4, 2021, through May 13, 2021, at DRG 521.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
(70553) provided on November 3, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services should be covered as you 
disagree with the charges. 
 
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 Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $325 copayment for the MRI. MRIs 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 
magnetic resonance imaging (MRI) (70553) provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) rendered by the out-of-network (OON) provider on October 29, 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 psychiatric diagnostic evaluation with medical services (90792) rendered by 
the out-of-network (OON) provider on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), influenza virus 
vaccine (90662), pneumococcal polysaccharide vaccine (90732), the administration of the influenza virus 
vaccine (G0008), and the administration of the pneumococcal vaccine (G0009) rendered by the out-of-network 
(OON) provider on November 22, 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), influenza virus vaccine (90662), 
pneumococcal polysaccharide vaccine (90732), the administration of the influenza virus vaccine (G0008), and 
the administration of the pneumococcal vaccine (G0009) rendered by the out-of-network (OON) provider on 
November 22, 2021.