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

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
(87635) provided on September 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that due to the COVID pandemic, tests must be 
done to travel and to re-enter the US. Your travel plans were made 8 months in advance. You did not receive 
the results in time and had to have testing done at the airport. 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. The Plan does not cover COVID-19 surveillance testing which is testing used for public 
health or social purposes such as employment (return to workplace), education, travel or entertainment. 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 infectious agent detection by nucleic acid (DNA or RNA) (87635) provided on 
September 12, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided by an out-
of-network physician on November 2, 2021. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that you were told by the 
office that they accepted your insurance and were in your Plan before the appointment was made. The Plan 
denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to in-network provider and professional 
services in an in-network specialist office.  
 
 
 The specialist office visit you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to in-network provider and professional 
services in an in-network specialist office. This cost sharing is a contractual obligation that had not been met at 
the time the specialist office visit was received on November 2, 2021. Therefore, we decided that the Plan does 
not have to waive the deductible for a specialist office visit provided by an out-of-network physician on 
November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the debridement of mastoidectomy 
cavity provided on August 11, 2021. 
 
You asked the Plan to increase the reimbursement for the debridement of mastoidectomy cavity. You say that 
you were told by the insurance plan that they would reimburse you due to the state of emergency. You also say 
during the pandemic, you could only go outside the network. The Plan denied your request. The Plan says you 
have been reimbursed the correct cost sharing amount. The Plan also says that the provider was out-of-network. 
 
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 $20 copayment for a specialist office visit.  
 
 The record shows this reimbursement claim was approved and processed correctly according to the Medicare 
Fee Schedule. Therefore, there is a cost sharing amount. The record also shows the amount of $104.95, which 
you are seeking reimbursement for, is not allowed by Medicare and cannot be reimbursed. The enrollee was 
reimbursed a total of $58.05 ($78.05 allowed amount - $20 copayment = $58.05). The enrollee has been asked 
to pay a $20 copayment for the debridement of mastoidectomy cavity. The debridement of mastoidectomy 
cavity falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This 
means that the enrollee has been reimbursed 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 increase the reimbursement for the debridement of mastoidectomy cavity 
provided on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from June 10, 2021, to June 30, 2021. 
 
You asked the Plan to waive the copayment for SNF stay. You say that this copayment amount is confusing 
and exceeded the enrollee's remaining out-of-pocket amount. The Plan denied your request. The Plan says the 
copayment amount the enrollee is being charged is correct. The Plan also says that they have reprocessed and 
reduced the copayment amount for this claim, so the enrollee is only responsible for $184. 
 
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 $0 copayment per day for days 1 to 20 and $184 copayment per day for days 21 to 100 for Skilled 
Nursing Facility (SNF) care.  This portion of the SNF stay lasted 21 days, which are days 1 to 21 of the benefit period, resulting in a 
copayment amount of $184. 
 
The enrollee has been asked to pay $0 copayment per day for days 1 to 20 and $184 copayment per day for 
days 21 to 100 for SNF stay. SNF stay falls within the Skilled Nursing Facility (SNF) Care 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 a skilled nursing facility (SNF) stay provided 
from June 10, 2021, to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82728, 83540, 83550 and 
83970 provided July 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that at this time, there is no contractual 
agreement in place which indicates that the CPT codes billed are included in the dialysis rate. It is your position 
that these CPT codes need to be reprocessed for payment due. The Plan denied your request. The Plan says the 
laboratory tests are included in the dialysis 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 documentation submitted showed that the laboratory tests reported were related to treatment of 
ESRD by end-stage renal disease was indicated as a reason for the laboratory tests, dialysis occurred on the 
same date as the tests, and a separate professional visit unrelated to ESRD was not indicated in the medical 
record. Therefore, the laboratory tests are included in the dialysis services and the claims for these laboratory 
services should be submitted to the dialysis center. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded as 82728, 83540, 83550 and 83970 provided July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 4, 2021. 
 
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 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 laboratory 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 the laboratory services provided on August 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 3, 2021, by an out-of-
network (OON) provider. 
 You asked the Plan to pay for psychotherapy. You say that your credentialing department is working on getting 
the Medicare product added to the existing contract for the providers, however that process has been taking 
some time. You also say that while they are working that out with the Plan, you are working on getting an 
authorization on file for futures dates of service. The Plan denied your request. The Plan says this provider is 
not a network provider with the plan and based on the documentation submitted, you have determined that the 
services rendered to the member are not urgent or emergent, nor were they approved in advance by a network 
provider. 
 
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 psychotherapy provided on December 3, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services (62324-26) provided on December 3, 
2021. 
 
You asked the Plan to pay for code 62324-26. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. The PC/TC indicator for CPT code 62324-26 is "0" = Physician 
service codes. This indicator identifies codes that describe physician services. Examples include visits, 
consultations, and surgical procedures. The concept of PC/TC does not apply since physician services cannot 
be split into professional and technical components. Modifiers 26 & TC cannot be used with these codes. The 
total Relative Value Units (RVUs) include values for physician work, practice expense and malpractice 
expense. There are some codes with no work RVUs. Each NCCI PTP edit has an assigned modifier indicator. 
A modifier indicator of "0" indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. The XE modifier shall only be used to describe separate encounters on the same date of service and a modifier 
indicator of 0 indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. In this case, 
CPT code 62324-26 has a modifier indicator of 0. Therefore, we decided that the Plan does not have to pay 
for the injection services (62324-26) provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 
14, 2021. 
  You asked the Plan to pay for the moderate sedation services (99153). You say that you are resubmitting the 
claim with attached medical records and the claim should be reviewed for payment. The Plan denied your 
request. The Plan says procedure code 99152 has been overturned and procedure code 99153 is not separately 
payable when performed by a physician in a facility setting. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99220) provided September 14, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not payable. 
 
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 99220 is initial observation care. 
 
We find that CPT code 99220 is not supported in the medical record. Specifically, only the admitting physician 
can bill for initial observation care. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99220) provided September 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you disagree with the charges, and 
you feel like its an unfair situation you have been put in. The Plan denied your request. The Plan says the 
copayment amount 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 $90 
copayment for the ER visit.  
 
You have been asked to pay a $90 copayment for the ER visit. ER visits fall 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 the ER visit provided on October 
19, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination (71045) provided on May 7, 
2021. 
 
You asked the Plan to pay for code 71045. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 32555. 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 Radiologic examination (71045) provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for brachytherapy (0394T) provided September 20, 2021. 
 
You asked the Plan to pay for the brachytherapy. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the billed code has a bundled relationship with another code billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0394T 
is a column II code to column I code 77401. 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 brachytherapy (0394T) provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Orthopedic Surgery provided on August 16, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Orthopedic Surgery. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Orthopedic Surgery provided on August 16, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided by a 
network provider on September 7, 2021. 
 
You asked the Plan to reduce the coinsurance for the Part B injection. You say that you have been overcharged. 
The Plan denied your request. The Plan says you have been asked to pay 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 other Part B covered drugs.  
 
You have been asked to pay $251.66 which is 20% of the allowed amount for the Part B injection. The allowed 
amount is $1,258.32. ($1,258.32 x 20% = $251.66). The Part B 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 reduce the coinsurance for the Part B injection provided by a network provider on 
September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified 
probe technique (87635) provided on October 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that due to the COVID-19 pandemic, tests are 
required to travel. Your travel plans were made 8 months in advance and your results were not back on time so 
you had to have a test completed at the airport which cost $250. 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. COVID tests for travel purposes are not covered. 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 
infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (87635) provided on October 4, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination of the chest (71045) provided on 
November 12, 2021. 
 
You asked the Plan to pay for code 71045. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that three separate chest x-rays were provided on November 12, 2021. The file shows that the Plan paid for two 
chest x-rays (1 unit of 71045-26 and 1 unit of 71045-26-76) provided on November 12, 2021. Therefore, we 
decided that the Plan does not have to pay for the radiologic examination of the chest (71045) provided on 
November 12, 2021.