Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6219) provided on August 
12, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for wound care supplies. You say that the items at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not 
been met. 
 
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 wound care supplies (A6196, A6219) provided on 
August 12, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on September 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
September 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on August 
1, 2021. 
 
You asked the Plan to pay for nursing facility care supervision. You say that this service was provided in good 
faith and meets professional recognized standards of healthcare. The Plan denied your request. The Plan says 
this service has a status indicator of "B", which means payment for this service is always bundle into payment 
for another covered service. 
 
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 99379 has a status indicator of B: Bundled Code. Payment for covered services are 
always bundled into payment for other services not specified. If RVUs are shown, they are not used for 
Medicare payment. If these services are covered, payment for them is subsumed by the payment for the 
services to which they are incident. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules for coverage of nursing facility care supervision have not been met. Therefore, we decided that the Plan does 
not have to pay for nursing facility care supervision (99379) provided on August 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echo guide for biopsy (76942) provided on May 11, 
2021. 
 
You asked the Plan to pay for the echo guide. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 36556 and 76942. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76942 
is a column II code to column I code 36556. 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 the echo guide for biopsy (76942) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for low frequency, non-contact, non-thermal ultrasound, 
including topical application, when performed, wound assessment, and instruction for ongoing care, per day 
(97610) provided March 22, 2021 to March 25, 2021. 
 
You asked the Plan to pay for the wound care services. You say that this treatment is medically necessary for 
the enrollee's condition as well as meets Medicare criteria. The Plan denied your request. The Plan says 
experimental or investigational services are not covered. 
 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 the wound care services have been met. 
The records show that the Plan made multiple requests to obtain clinical records from the provider without 
success. Therefore, we decided that the Plan does not have to pay for low frequency, non-contact, non-thermal 
ultrasound, including topical application, when performed, wound assessment, and instruction for ongoing care, 
per day (97610) provided March 22, 2021 to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a euflexxa injection (code J7323) provided 
on November 16, 2021. 
 
You asked the Plan to waive the coinsurance for a euflexxa injection. You say that you had three arthrocentesis 
procedures and were told there would be no charge for the injections. 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 20% 
coinsurance for part B drugs.  
 The records show you had a euflexxa injection on November 16, 2021. A euflexxa injection is a separately 
payable service. You have been asked to pay $55.23, which is 20% of the allowed amount for a euflexxa 
injection ($277.64 allowed amount x 20% coinsurance = $55.53). A euflexxa injection falls within the 
Medicare Part B Prescription Drugs 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 a 
euflexxa injection provided on November 16, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on July 20, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct date of service. 
 
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 Guardant360 testing 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 Guardant360 testing (0242U) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided on October 4, 
2021. 
 
You asked the Plan to pay for acupuncture services. You say that this has been covered in the past. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
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 chronic low back pain (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. Specifically, the submitted records do not document that the 
enrollee has chronic low back pain. The duration of the enrollee's pain is not included in the records. Therefore, 
we decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided on October 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on September 9, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that these denied services are covered per 
your dental plan. The Plan denied your request. The Plan says these services are not covered benefits under 
your dental plan. The Plan also says that the benefits you were referring to are under the supplemental dental 
rider which you were not enrolled in on this date of service. 
 
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 crown 
(D2740) and core buildup, including any pins when required (D2950) provided on September 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the integrated biopsychosocial assessment (90791) provided 
on November 24, 2021 to December 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that you are requesting reconsideration of 
these dates of services. They should be covered because they were all submitted within 1 year time frame form 
the original dates of service. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being 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 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 integrated biopsychosocial assessment (90791) 
provided on November 24, 2021 to December 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses and anti-reflective coating provided on 
December 3, 2021. 
 
You asked the Plan to pay for progressive lenses and anti-reflective coating. The Plan denied your request. The 
Plan says progressive lenses with an anti-reflective coating are not covered under your benefit. 
 The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined 
by Medicare. Progressive lenses, no-line bifocal or trifocal lenses, tinting (except for certain ultraviolet-
screening coatings), scratch-resistant coatings, or oversized lenses are not covered unless required by Medicare 
coverage guidelines. 
 
We looked at the file and the Plan's rules. The file shows that the Plan covers eyeglasses after cataract surgery 
includes standard frames and lenses as defined by Medicare. Progressive lenses with an anti-reflective coating 
are not covered under your benefit. Therefore, we decided that the Plan does not have to pay for progressive 
lenses and anti-reflective coating provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on May 6, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that clinical documentation demonstrates the 
medical necessity for the anesthesia billed. You say that the claim should be reviewed and reprocessed to pay 
accordingly. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services coded as 99215, 11106 and 17004 
provided October 12, 2021. 
 
You asked the Plan to pay for the dermatology services. You say that you feel that this should be covered as 
you were unaware of the providers status. The Plan denied your request. The Plan says services were rendered 
by an opt-out provider. 
 
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 the 
dermatology services coded as 99215, 11106 and 17004 provided October 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 13, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services to the member in good faith, and the rendered services meet professionally recognized 
standards of healthcare. 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. 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 subsequent nursing facility care provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthotic and prosthetic supplies provided 
on August 17, 2021. 
 
You asked the Plan to waive the coinsurance for orthotic and prosthetic supplies. You say that this is not 
durable medical equipment and you are not paying 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay $3,886.47, which is less than the 20% coinsurance for orthotic and prosthetic 
supplies. Orthotic and prosthetic supplies fall within the prosthetic devices 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 orthotic and prosthetic supplies provided on 
August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for arthrocentesis provided from October 26, 
2021, to November 16, 2021. 
 
You asked the Plan to waive the copayments for arthrocentesis. You say that you disagree with the total 
copayment charges of $780 because you were told that you would not owe anything for the injections. 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 $260 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 The record shows that you received arthrocentesis at an outpatient hospital facility from October 26, 2021, to 
November 16, 2021, for a total of 3 services. Arthrocentesis is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay a $260 copayment per each service. The total amount you owe is: $260 
(copayment) x 3 (outpatient hospital services) = $780.   
 
You have been asked to pay the total copayment amount of $780 for arthrocentesis. Arthrocentesis 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 arthrocentesis provided from 
October 26, 2021, to November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the application to the leg of a multi-layer 
wound care compression system (29581) provided on September 17 to October 29, 2021. 
 
You asked the Plan to waive the copayments for the application to the leg of a multi-layer wound care 
compression system. You say that the Plan is charging the copayment for surgical procedures when there was 
absolutely no surgery involved. The Plan denied your request. The Plan says the correct copayments were 
applied. 
 
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 $225 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $206.75 copayment for each date of service for the application to the leg of a multi-layer wound care compression system. The application to the leg of a multi-layer wound care 
compression system was performed at an outpatient hospital facility and therefore falls within the "Outpatient 
hospital services" benefit category. This means that you have been asked to pay less than or equal to the full 
and 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 the application to the leg of a multi-layer wound care compression system (29581) provided on 
September 17 to October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you were told that you 
would only owe a $50 copayment. 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 $100 
copayment for outpatient diagnostic tests provided in an outpatient hospital facility. 
 
You received an ultrasound of the heart at an outpatient hospital facility on November 8, 2021. Therefore, you are responsible to pay the $100 copayment.   
 
You have been asked to pay a $100 copayment for an ultrasound of the heart. An ultrasound of the heart 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 an ultrasound of the heart provided on November 8, 2021.