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

 
We decided that the Plan does not have to reduce the cost-share for the outpatient services provided on 
November 24, 2021. 
 
  You asked the Plan to reduce the cost-share for the outpatient services. You say that you do not understand 
why the current facility is able to charge $700 more than the previous sister facility. You say that you were 
never advised in advance that the cost would be more even though both facilities are in the same healthcare 
system. The Plan denied your request. The Plan says the cost-share applied 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 20% 
coinsurance for each Medicare-covered Part B drug, chemotherapy drug and the administration of that drug. 
The Plan also says that you pay 20% for each Medicare-covered medical supply and a $335 copayment for 
Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited 
to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a total of $1,705.37 for the outpatient services.  
 
Date of Service Service/Billing Code Allowed 
Amount 
Cost Per 
Contract 
Member Share 
November 24, 2021 Part B Drugs $7,271.70 20% $1,454.34 
November 24, 2021 Chemotherapy Administration  $384.12 20% $76.82 
November 24, 2021 Medical Supplies $13.06 20% $2.61 
November 24, 2021 Injection of Additional Drug 
(96375) 
$171.60 $335 
copayment 
$171.60 
Total  $7,840.48  $1,705.37 
 
The Part B drugs and chemotherapy administration fall within the Medicare Part B Prescription Drugs benefit 
category. Medical supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The injection of additional drug falls within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the cost-share for the outpatient services provided on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided April 11, 2022. 
 
You asked the Plan to pay for lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. 
 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for lab services (83789) provided April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 7, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test assists in the treatment, prognosis, and 
diagnosis of cancer. The Plan denied your request. The Plan says the testing is not FDA approved. 
 
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 looked at the file and the rules. The documentation shows that the testing has not been cleared or approved 
by the FDA. The panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64488 and 49657 billed for date of service 
December 10, 2021. 
  You asked the Plan to pay for procedure code 64488. You say that the CPT codes are correctly billed, and 
supportive documentation is attached. The Plan denied your request. The Plan says procedure code 49657 has 
been overturned and procedure code 64488 cannot be billed with a modifier to bypass the edit. 
 
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 64488 
is a column II code to column I code 49657 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 64488 and 49657 billed for date of service December 10, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection with imaging guidance 1 level (2 
requested) and facet joint injection with imaging guidance 2nd level (2 requested) to be provided by an out-of-
network (OON) facility. 
 
You asked the Plan to pre-approve facet joint injection with imaging guidance 1 level (2 requested) and facet 
joint injection with imaging guidance 2nd level (2 requested) to be provided by an out-of-network (OON) 
facility. You say that you believe the request was denied in error, due to physician/facility being out-of-
network. The Plan denied your request. The Plan says the facility chosen is not in-network. 
 
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 
facet joint injection with imaging guidance 1 level (2 requested) and facet joint injection with imaging 
guidance 2nd level (2 requested) to be provided by an out-of-network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 21, 2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace provided on February 18, 
2022. 
 
You asked the Plan to waive the coinsurance for a back brace. You say that you were told there would be no 
charge for this. The Plan denied your request. The Plan says the cost share was 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $132.75 for a back brace. A back brace 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 a back brace provided on February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 22854, 20931) provided to 
the enrollee on May 16, 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 denied codes are not supported by the 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 the denied codes is: 
 
CPT 20931: 
 
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
 
CPT 22854: 
 
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) 
(vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each 
contiguous defect (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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that both of these codes should remain 
denied. There is no documentation of vertebral corpectomy or structural allograft usage.  
 
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 surgical services (procedure code 22854, 20931) provided to the enrollee on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81317, 81292, 81298, 81295, 81300, 81297, 
81319, 81294) provided April 7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that  if a laboratory assays 2 or more genes in a 
patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so 1 procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were submitted for the same genetic testing panel. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81317, 81292, 81298, 81295, 
81300, 81297, 81319, 81294) provided April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography with radiological supervision (procedure code 
75726) provided to the enrollee on March 26, 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 code cannot be verified. 
 
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 75726 is "Angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation." 
 
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 Medicare guidelines specify that 
any procedure related to road-mapping for an interventional procedure should not be billed as a separate code 
from the reimbursed procedure which in this case was 37244. Thus, the billed charge of 75726 which is for 
angiography would be considered road-mapping for the embolization procedure and thus part of 37244.  
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 angiography with radiological supervision (procedure code 75726) provided to the enrollee on 
March 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of a duplex scan (procedure code 93970) 
provided to the enrollee on September 25, 2021. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says codes with an MAI of "3" have been rigorously reviewed and vetted by the Centers for 
Medicare and Medicaid Services and are designated this MAI because it would be possible but medically 
highly unlikely that higher values would represent correctly reported services.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93970 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study." 
 
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 additional units. Our reviewer says that the additional 
units at issue in this case were not supported by the medical records. Our reviewer found that there is only one 
exam done on 9/25/21 under order # ending in 8928BP. Thus, reimbursement for one unit of CPT 93970 would 
have been appropriate. The additional unit is not reasonable. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for additional units of a duplex scan (procedure code 93970) provided to the enrollee on 
September 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
May 4, 2022. 
 
You asked the Plan to pay for the determination of refractive state. The Plan denied your request. The Plan says 
refractive services are not covered under your medical benefit plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of multiple defects of retina without detachment. Based on this information, we decided that the 
Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that 
the Plan does not have to pay for the determination of refractive state (92015) provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on October 5, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 office visit and related services provided on 
October 5, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D7250, D6010, D6056, D7953) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve 
dental services (D7250, D6010, D6056, D7953)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and bifocal lenses (V2200) provided on 
April 26, 2022. 
   
You asked the Plan to pay for frames (V2020) and bifocal lenses (V2200). You say that you tried to go to at 
least ten different in-network providers. You also say that many were closed. You also say you could not find 
others because of incorrect addresses. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of frames (V2020) and bifocal lenses (V2200) have not been met. Specifically, the frames and lenses 
were received from a non-network provider. Therefore, we decided that the Plan does not have to pay for 
frames (V2020) and bifocal lenses (V2200) provided on April 26, 2022.