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

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 2, 
2022 and billed under code 77012. 
 
You asked the Plan to pay this claim. You say that this claim should be paid. The Plan denied your request. The 
Plan says the Medicare guidelines indicate a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between codes 62328 and 77012. This PTP edit has a modifier indicator of 1, 
which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not 
billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, code 77012 cannot be paid due to the 
omission of a required modifier. Medicare rules for coverage of this code were not met. Therefore, we decided 
that the Plan does not have to pay for imaging services provided to the enrollee on September 2, 2022, and 
billed under code 77012.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810, 97811, and 97026), 
provided on December 20, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says the services were obtained by a non-covered provider type. 
 
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. Specifically, these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services (97810, 97811, and 97026), provided on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81227, 81230, 81231, 81232, 81291, 81306, 
81328, 81355, 81335, 0031U, 0032U, 0033U) provided on January 31, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says multiple codes were billed for a single panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single 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 (81227, 81230, 81231, 81232, 
81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U) provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on May 23, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected (May 11, 2022). 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 (81479) provided on May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, & 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 1, 2022, billed with codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, & 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the arthrocentesis, aspiration and/or 
injection (20611), radiologic exam (73502), and office visit (99213), provided on January 27, 2022, and 
February 24, 2022. 
 
You asked the Plan to waive the deductible for the arthrocentesis, aspiration and/or injection, radiologic exam, 
and office visit. You say that there should not be a 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 $225 
deductible for Medicare Part B prescription drugs, outpatient diagnostic tests and physician services.  
 You have been asked to pay a $225 deductible for the arthrocentesis, aspiration and/or injection, radiologic 
exam, and office visit.  This item/service falls within the Medicare Part B prescription drugs, outpatient 
diagnostic tests and physician 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 deductible for 
the arthrocentesis, aspiration and/or injection (20611), radiologic exam (73502), and office visit (99213), 
provided on January 27, 2022, and February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for the billed CPT code is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on February 15, 2022.
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 May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. 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 May 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 surveillance testing/screening (including an at-
home over the counter COVID-19 test) provided on January 17, 2022. 
 
You asked the Plan to pay for this testing. You say that this testing should be paid for by the Plan. The Plan 
denied your request. The Plan says based on Medicare guidelines you are responsible for the entire cost of the 
service rendered in the amount of $102.73. Per Medicare guidelines, COVID-19 testing for non-diagnostic 
testing for screening purposes is not covered by Medicare. Per your 2022 Evidence of Coverage, if you 
get services that are excluded (not covered), you must pay for the services. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in 
the Medicare rules section, are not covered. This testing was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for COVID-19 surveillance testing/screening (including an at-home over the counter COVID-19 test) provided 
on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the service should be covered. 
The Plan denied your request. The Plan says prior authorization must be obtained for out-of-network services. 
 
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 subsequent nursing facility care provided on 
July 14, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional endotracheal intubation provided to the 
enrollee on April 22, 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 there are no medical records that show that the enrollee intubated, extubated, and then intubated 
again. 
 
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 31500 is "Intubation, endotracheal, emergency 
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 the records submitted do not 
indicate that two separate services (CPT 31500) were performed. The medical records provided show that only 
one emergency endotracheal intubation was performed on 04/22/2022. There are no medical records showing 
that the enrollee/patient was intubated and then subsequently reintubated on 4/22/2022. The medical records 
submitted do not support the second billing of CPT 31500. 
 
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 an additional endotracheal intubation provided to the enrollee on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 15, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, & 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 15, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 
0031U, 0032U, & 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81479 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultralightweight wheelchair with options and accessories 
billed for date of service June 21, 2022. 
 
You asked the Plan to pay for the ultralightweight wheelchair with options and accessories. You say that this 
chair was authorized and was medically necessary. The Plan denied your request. The Plan says the proof of 
delivery does not support the date of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for durable medical equipment, the general rule 
is that the date of service is equal to the date of delivery. You billed with a date of service of June 21, 2022.  
However, the delivery ticket (with the enrollee's signature acknowledging receipt of the item(s)), is dated June 
8, 2022.  Therefore, the proof of delivery you provided does not support the date of service that you billed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultralightweight wheelchair with options and accessories have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultralightweight wheelchair with options and accessories 
billed for date of service June 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on July 03, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not have to pay 
for the emergency room visit 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for emergency room visit. This item/service falls within the 
emergency 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 emergency room visit 
provided on July 03, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 23, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the guidelines indicate a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 70496 and 70450 This PTP edit has a modifier indicator of 1, which 
indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not 
billed with this PTP code edit 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to 
the omission of a required modifier. Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 
23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 15, 2021. 
 
You asked the Plan to pay for an office visit (99214). You say that it is not your fault that the payment was not 
made. The Plan denied your request. The Plan says the requested explanation of benefit (EOB) was not 
received within the allotted timeframe. 
 
  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
with the provider that they submitted the claim to the primary insurance company, and they are now awaiting 
payment information from them. As the secondary insurer, the Plan cannot be held responsible for an office 
visit (99214) until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for an office visit (99214) provided on November 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services you received on April 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
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. Licensed professional counselors are not eligible to enroll in the Medicare program. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy services you received on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 19, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldnt have to pay 
for this. 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 $45 
copayment for Specialist office visits. 
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
Specialist office visits 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 specialist 
office visit provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 23, 
2021, by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that your doctors were the only 
providers who were able to treat the patients due to the COVID-19 pandemic. The Plan denied your request. 
The Plan says the out-of-network services were not 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/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 domiciliary or rest home visit provided on 
September 23, 2021, by an OON provider.