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

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on June 16, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that this was an emergency that required 
treatment, but you did not require transport to the hospital. The Plan denied your request. The Plan says this 
service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on June 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided on June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient stay provided on December 
29, 2021. 
 
You asked the Plan to waive the coinsurance for an inpatient stay. You say that you should not have to pay this 
large coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for inpatient services. You met your out-of-pocket maximum (MOOP) for 2021 during this 
inpatient stay, resulting in a $551.90 which is less than the 10% coinsurance. 
 
You have been asked to pay a $551.90 coinsurance for an inpatient stay. This item/service falls within the 
inpatient 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 an inpatient stay 
provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) and infrared light therapy (97026) provided February 1, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that this documentation supports the medical 
necessity services provided to the enrollee. Please reconsider the previously denied claim. The Plan denied your request. The Plan says the services does not meet the coverage requirements in the applicable Local 
Coverage Determination or National Coverage Determination. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, The services were rendered by a licensed 
acupuncturist, not a physician. Infrared therapy is not a covered service. Therefore, we decided that the Plan 
does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes 
(97811) and infrared light therapy (97026) provided February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 
88104 provided on December 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. These services were billed with a place 
of service 22 (outpatient hospital). The professional interpretation was furnished in the same payment locality 
from where the technical component was furnished. Diagnostic tests must be separately billed with modifier-26 
by the interpreting physician. This means that this claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 88104 provided 
on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88381 billed for date of 
service January 8, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, and 88381. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the codes are included in the skilled nursing facility 
payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that the services were provided to the enrollee while a SNF inpatient. Per the Physician 
Fee Schedule, CPT codes 88341, 88342, and 88381 have a Professional/Technical indicator of 1. This means 
that CPT codes 88341, 88342, and 88381 have both a professional and technical component. In this case, CPT 
codes 88341, 88342, and 88381 have not been billed with an appropriate modifier to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of procedure codes 88341, 
88342, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 88341, 88342, and 88381 billed for date of service January 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 15271-AS, 15272-AS, and 15275-AS billed for date of 
service April 26, 2022. 
 
You asked the Plan to pay for codes 15271-AS, 15272-AS, and 15275-AS. You say that you have provided 
medical records to support payment. The Plan denied your request. The Plan says these codes are not eligible 
for an assistant surgeon. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 15271-AS, 15272-AS, and 15275-AS. The Medicare Fee Schedule 
Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that 
an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that 
Medicare coverage criteria for codes 15271-AS, 15272-AS, and 15275-AS have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 15271-AS, 15272-AS, and 15275-AS billed for date of 
service April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custodial care visit at an assisted living facility (99334) 
provided on December 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a custodial care visit. You say that the provider rendered services to the enrollee 
in an assisted living facility. The provider does not have prior knowledge of the patients who need care and 
therefore, does not confirm eligibility before providing care in good faith. The Plan denied your request. The 
Plan says the claim was processed correctly. There was no prior authorization for the services rendered. When 
a provider is not participating with the enrollees Plan, an authorization must be obtained prior to rendering 
services, or the circumstances of care must be urgent or emergent in nature. 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 a custodial care visit at an assisted living facility 
(99334) provided on December 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service April 10, 
2022. 
 You asked the Plan to pay for procedure code 64450. You say that this code was a separate procedure and 
should be paid. The Plan denied your request. The Plan says payment for code 64450 is bundled into payment 
for code 29130. 
 
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 64450 
is a column II code to column I code 29130. 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 procedure code 64450 billed for date of service April 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services on May 
10, 2022, to June 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health services. You say that you would like 
to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each individual or group therapy visit for Medicare-covered outpatient mental health services 
for outpatient mental health services. The total cost share is $150. 
 
You have been asked to pay a $25 copayment for each individual or group therapy visit for Medicare-covered 
outpatient mental health services for outpatient mental health services. This item/service falls within the 
outpatient mental health care 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 outpatient 
mental health services on May 10, 2022, to June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic laboratory services (93244) 
provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic laboratory services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $5 copayment for the diagnostic laboratory services. This item/service 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 copayment for diagnostic laboratory services (93244) provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a follow-up office visit provided on March 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the claim denied for the absence of a 
preauthorization. You say the services were medically necessary. The Plan denied your request. The Plan says 
the provider is out-of-network, and no prior authorization was received. The Plan also says that there were no 
urgent nor emergent issues diagnosed or evaluated during the visit. 
 
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 a follow-up office visit provided on March 9, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on March 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed code CPT 99285 had to be downcoded to CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 that the medical decision making was 
not of high complexity. The review has determined that the records did not support the original coded 99285. 
The downcoded 99284 is more appropriate. 
 
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 emergency room services (procedure code 99285) provided to the enrollee on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinary tract infection panel provided on November 8, 
2021. 
 
You asked the Plan to pay for a urinary tract infection panel. You say that this is a covered service. The Plan 
denied your request. The Plan says this was not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be, covered laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician.  
 
We looked at the file and Medicare rules. The order included in the records is not signed by a physician. Based 
on this information, we decided that Medicare rules for coverage of a urinary tract infection panel have not 
been met. Therefore, we decided that the Plan does not have to pay for a urinary tract infection panel provided 
on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 28, 2022, to April 30, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per day for the first six days of an inpatient hospital stay.  
 
You have been asked to pay a $600 copayment for an inpatient hospital stay ($300 copayment  2-day hospital 
stay = $600 copayment). This service falls within the inpatient hospital care 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 inpatient hospital stay provided from April 
28, 2022, to April 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that the service at issue was billed correctly. The 
Plan denied your request. The Plan says payment for code 88305 is bundled into payment for code 88321. 
 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 88305 
is a column II code to column I code 88321. 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 procedure code 88305 billed for date of service May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoe lift provided on April 11, 2021 to December 7, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the shoe lift. You say that the shoe lift was medically necessary. The Plan denied 
your request. The Plan says the out-of-network service was not emergent or pre-authorized. 
 
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 at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for a shoe lift provided on April 11, 2021 to December 7, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for walker on July 19, 2022. 
 
You asked the Plan to waive the coinsurance for walker. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% 
coinsurance at a durable medical equipment provider. Covered items include but are not limited to walkers.  
The provider billed in the amount of $95 and the Plan exclusions is -$95. The provider billed in the amount of 
$30 and the Plan exclusions is $10.62. $30 - $10.62 = $19.38. $19.38 x 30% = $5.81. Therefore, results in the 
total cost sharing amount of $5.81. 
 
You have been asked to pay a 30% coinsurance for walker. This item/service falls 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 walker on July 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on June 
2, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
(90837) provided on June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436, & 84479 billed for date of service 
March 9, 2022. 
 You asked the Plan to pay for procedure codes 84436, & 84479. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 84436, & 84479 is bundled into 
payment for code 84439. 
 
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 
84436, & 84479 are column II codes to column I code 84439. 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 procedure codes 84436, & 84479 billed for 
date of service March 9, 2022.