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

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services have been requested out-of-network and there are in-
network providers available. 
 
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 outpatient visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure (81479) provided on 
March 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the molecular pathology procedure. You say that  The Plan denied your request. 
The Plan says the services were provided out-of-network and were not approved in advance. 
  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 molecular pathology procedure (81479) 
provided on March 26, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies with pump and injection, milrinone lactate, 
5 mg provided from October 14, 2021, to October 23, 2021. 
 
You asked the Plan to pay for infusion supplies with pump and injection, milrinone lactate, 5 mg. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the members terminal condition. The Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for infusion supplies 
with pump and injection, milrinone lactate, 5 mg provided from October 14, 2021, to October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic visits provided on January 17, 2022, to April 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic visits. You say that this provider is in-network. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 chiropractic visits provided on January 17, 
2022, to April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravascular ultrasound (37253) provided on November 
17, 2021. 
 
You asked the Plan to pay for the intravascular ultrasound (37253). You say that the claim should be reviewed 
for payment. The Plan denied your request. The Plan says procedure code 37253 is not supported by the 
medical records submitted. 
 
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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 
  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 intravascular ultrasound (37253). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the documentation is insufficient to confirm an intravascular ultrasound was performed. 
 
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 intravascular ultrasound (37253) have not been met. Therefore, we decided 
that the Plan does not have to pay for the intravascular ultrasound (37253) provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
March 30, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that the enrollee has medical 
conditions that puts them at higher risk when put under anesthesia. You say that the claim should be reviewed 
and reprocessed for additional payment. The Plan denied your request. The Plan says procedure codes 99100 
and 99140 are considered bundled and 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 procedure code. 
  We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided on November 2, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says 
acupuncturist are not able to be reimbursed by Medicare. 
 
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.  
 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. Therefore, we decided that the Plan does not have to pay for 
acupuncture treatment provided on November 2, 2021.
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, level 1 (A0427) and ground mileage (A0425) provided December 7, 2021. 
 
You asked the Plan to waive the copayment for the emergency ambulance services and ground mileage. You 
say that this service was not due to a work-related injury. The Plan denied your request. The Plan says the 
copayment has been applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $270 copayment per date of service for ground and air ambulance services. 
 
The enrollee has been asked to pay a $270 copayment for the emergency ambulance services and ground mileage. The emergency ambulance services, and ground mileage fall within the Ambulance services benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling 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, level 1 (A0427) and ground mileage (A0425) provided December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast biopsy with localization device placement (19081) 
billed on August 11, 2021. 
 
You asked the Plan to pay for the breast biopsy with localization device placement (19081). You say that the 
report supports the medical necessity of the service, and the claim should be reconsidered for reimbursement. 
The Plan denied your request. The Plan says the denial is upheld due to failure to provide the requested 
documentation. 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the breast biopsy with localization 
device placement (19081) have been met. Specifically, medical records were not submitted to determine if 
payment should be issued. Therefore, we decided that the Plan does not have to pay for the breast biopsy with 
localization device placement (19081) billed on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were reported correctly. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20931, 63081 and 63082 billed on June 21, 
2021. 
 
You asked the Plan to pay for procedure codes 20931, 63081 and 63082. The Plan denied your request. The 
Plan says procedure codes 20931, 63081 and 63082 are not supported by the medical records submitted. 
 
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 20931 is allograft, structural, for spine surgery only (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 63081 is 
vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of 
spinal cord and/or nerve root(s); cervical, single segment. The CPT Code Manual definition of code 63082 is 
vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of 
spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for 
primary procedure). 
 
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 procedure codes 20931, 63081 and 63082. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not include enough documentation to confirm allograft, structural for spine 
and a partial or complete vertebral corpectomy were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 20931, 63081 and 63082 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 20931, 63081 and 63082 billed on June 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the enrollee has medical conditions that puts 
them at higher risk when put under anesthesia. You say that the description of services documents the 
qualifying circumstances that enable this code to be paid. The Plan denied your request. The Plan says 
procedure code 99100 is considered bundled and 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 procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 25, 
2022, to February 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network 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 outpatient mental health services provided on 
January 25, 2022, to February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0367) provided on April 26, 2022. 
 
You asked the Plan to pay for imaging. You say that this service should be covered. The Plan denied your 
request. The Plan says cone beam imaging (D0367) is not covered by your 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 cone 
beam imaging (D0367) provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on May 2, 2022 
 
You asked the Plan to waive the copayment for lab work. You say that if you had known there would be a 
copayment for labs, you would have waited to get it done until you had an appointment with the provider. The 
Plan denied your request. The Plan says the copayment applied was 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 a $10 
copayment for Medicare-covered laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for lab work. Lab work falls within the Medicare-Covered 
Laboratory Tests That Are Not FIT Tests 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 lab work provided on May 2, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 22, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have a copayment for 
this service, as you had the x-ray done at your provider's office. The Plan denied your request. The Plan says 
the copayment applied was 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 a $95 
copayment for outpatient hospital services, basic radiological services.  
 
You have been asked to pay a $95 copayment for an x-ray. An x-ray falls within the Outpatient Hospital 
Services, Basic Radiological Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an x-ray provided on April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve Enbrel. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Enbrel is not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel.  
 
Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided April 20, 2022. 
 
You asked the Plan to pay for the pulp vitality tests. You say that the care received was appropriate and should 
be covered. The Plan denied your request. The Plan says this service is not covered under 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. 
 
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 the pulp 
vitality tests (D0460) provided April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery on April 19, 2022, to 
April 26, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgery. You say that these claims should be 
covered in full because you are being billed for services you didn't receive. You feel these services are a 
surgical procedure because they just scraped your wound. They are billing 3 times the amount for the care you 
received. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per visit for outpatient surgery. If you are having surgery in a hospital facility, you should check 
with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to 
admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient 
surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. There were 
two dates of service. $325 x 2 = $650. Therefore, results in the total cost sharing amount of $650. 
 
 You have been asked to pay a $325 copayment per visit for outpatient surgery. Outpatient surgery falls within 
the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for outpatient surgery on April 19, 
2022, to April 26, 2022.