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

 
We decided that the Plan does not have to pay for laboratory services provided on October 11, 2023, billed 
with codes 87652, 87798, 87799, 87900, 87481, 87500 and 87640. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on October 11, 2023, billed with codes 87652, 
87798, 87799, 87900, 87481, 87500 and 87640.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938-TC, 95861-TC, 95868-TC, 95927-
TC, and 95940 billed for date of service August 1, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940. You 
say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says these 
codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938-TC, 95861-TC, 
95868-TC, 95927-TC, and 95940. This means there is both a professional and technical component for the CPT 
code(s). In this case, an appropriate modifier to indicate the professional component has not been billed with 
CPT code(s) 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95938-TC, 
95861-TC, 95868-TC, 95927-TC, and 95940 billed for date of service August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, 
and 80061 provided on March 27, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 80061. 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 find that procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 80061, have a status indicator of 
X on the Physician Fee Schedule. This means that procedure codes 36415, 84439, 84443, 85025, 80053, 
83036, and 80061, represent an item or service that is not in the statutory definition of "physician services" for 
fee schedule payment purposes. No payment amounts are shown for these codes, and no payment may be made 
under the physician fee schedule. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 80061, have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 36415, 84439, 84443, 85025, 80053, 83036, and 
80061 provided on March 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 18, 2023, to August 23, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you paid a lower 
copayment the last time. 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 $350 
copayment for inpatient hospital care. 
 
You have been asked to pay a $350 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital 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. You have been asked to pay a total of $1,400 for the inpatient hospital stay ($350 
copayment x 4 days = $1,400). Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided on August 18, 2023, to August 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87631, 87481, 87486, 87491, 87496, 
87498, 87532, 87541, 87551, 87556, 87561, 87581, 87640, 87641, 87651, 87653, 87798, 87481) provided on 
July 10, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this test was a panel which should be billed 
with only a single panel code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87631, 87481, 87486, 87491, 87496, 87498, 87532, 87541, 
87551, 87556, 87561, 87581, 87640, 87641, 87651, 87653, 87798, 87481) provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visits, and outpatient 
surgery provided on February 27, 2023, to March 27, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visits and skin grafts. You say that you do 
not agree with the amount that you were billed for the services you received. 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 $350 
copayment for outpatient hospital facility and a $40 copayment per specialist visit.  
 
  You have been asked to pay a total of $1,520 for the specialist office visits and skin grafts.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 27, 2023 Specialist visit $151.05 $40 $40 
February 27, 2023 Outpatient surgery $1,811.60 $350 $350 
March 6, 2023 Specialist visit $131.35 $40 $40 
March 6, 2023 Outpatient surgery $1,811.60 $350 $350 
March 13, 2023 Specialist visit $153.76 $40 $40 
March 13, 2023 Outpatient surgery $1,811.60 $350 $350 
March 27, 2023 Outpatient surgery $391.60 $350 $350 
TOTAL:    $1,520 
 
This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
and outpatient and physician/practitioner services, including doctors 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 the specialist office visits, and outpatient surgery provided on 
February 27, 2023, to March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on September 11, 2023.  
 
You asked the Plan to waive the deductible for the office visit. You say that you were unaware that this 
provider is out-of-network, and you want the claim to process at the in-network level as it applied to your out-
of-network deductible. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service 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 a $300 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on September 11, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the office visit on September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497-25 billed for date of service April 11, 
2023. 
 You asked the Plan to pay for procedure code 99497-25. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 99497-25 is bundled into payment for 
code 99223. 
 
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 
99497-25 is a column II code to column I code 99223. 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 99497-25 billed for date of service 
April 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on April 11, 2023, to April 
27, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that these services are not covered when 
provided OON without prior authorization. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the outpatient services provided on April 11, 2023, to April 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on May 16, 2023. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you are asking the plan to review and 
remove the charge that was applied as your responsibility. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for the x-ray. This item/service 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. However, since the allowed amount is less than the standard 
copayment, you only owe $79.31. Therefore, we decided that the Plan does not have to waive the copayment 
for the x-ray provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial maxillary denture (D5211) provided on September 22, 
2023. 
 
You asked the Plan to pay for partial maxillary denture (D52211) provided on September 22, 2023.. You say 
that you paid a portion and the Plan should pay the rest. The Plan denied your request. The Plan says this is not 
a covered benefit. 
 
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 partial 
maxillary denture (D5211) provided on September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the zoster (shingles) vaccine (90750) provided September 6, 
2023. 
 
You asked the Plan to pay for the vaccination services. You say that you received the Notice of Denial of 
Payment regarding your shingles vaccine shot. You have paid in full for it and you were told you should get 
reimbursed. The Plan denied your request. The Plan says the vaccine received, and the administration cost is 
covered only under your Part D benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for the zoster (shingles) vaccine (90750) provided September 6, 2023.  
 Benefits for the vaccination services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 13, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed testing is not 
covered when billed with code 81479. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the file shows that the billed unique identifier, ZB1CW, 
was reported with code 81479. This testing is covered when billed with unique identifier ZB1CW and code 
0326U. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 13, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
24, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not understand why 
you are being billed. 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 $310 
copayment for in and out-of-network Medicarecovered oneway trip via ground ambulance. 
 
You have been asked to pay a $310 copayment for ambulance services. This item/service falls within the in and 
out-of-network Medicarecovered oneway trip via ground ambulance 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 ambulance services provided on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive series of intraoral x-rays (D0210) and 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions (D0431) provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have been a resident of your state for less 
than one year. You also say this Plan has been your insurance provider for less than one year. The Plan denied 
your request. The Plan says your benefit comprehensive series of intraoral x-rays (D0210) has already been 
exhausted. The Plan also says that adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 
including premalignant and malignant lesions (D0431) is not a covered benefit. 
 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 comprehensive series of intraoral x-rays (D0210) was exhausted on date of service 
September 6, 2023. The record also shows that adjunctive pre-diagnostic test that aids in detection of mucosal 
abnormalities including premalignant and malignant lesions (D0431) is excluded from this benefit. Therefore, 
we decided that the Plan does not have to pay for comprehensive series of intraoral x-rays (D0210) and 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions (D0431) provided on September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the infusions, the injections, the 
chemodenervation services, and the TTE. 
 
You asked the Plan to waive the cost sharing for the infusions, the injections, the chemodenervation services, 
and the TTE. You say that you do not agree with being charged different copayment and coinsurance amounts. 
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 $40 
copayment for each Medicare-covered specialty care visit (when services are provided by a specialist or other 
healthcare professional), a 20% coinsurance of the total cost for Medicare-covered Part B drugs, a $275 
copayment for Medicare-covered surgical services performed in an outpatient department of a hospital, and a 
20% coinsurance for Medicare-covered diagnostic tests. 
 
You have been asked to pay a $80 copayment for the infusions ($40 copayment x 2 services = $80). These 
items/services fall within the physician/practitioner services, including doctors office visits benefit category. 
You have been asked to pay a $136.78 coinsurance for the injections ($683.97 allowed amount x .20 = $136.78 
rounded down). These items/services fall within the Medicare Part B prescription drugs benefit category. You 
have been asked to pay a $35 copayment for the chemodenervation performed on May 25, 2023, because the 
Plan is only holding you responsible for this amount which is less than the $275 copayment. You have been 
asked to pay a $275 copayment for the chemodenervation performed on September 1, 2023. These 
items/services fall within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. You have also been asked to pay a $97.35 coinsurance for the 
TTE ($486.76 allowed amount x .20 = $97.35). This item/service 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 cost sharing for 
the intravenous infusions, and injections provided on October 7, 2022, the chemodenervation of extremity 
provided on May 25, 2023, and September 1, 2023, and the transthoracic echocardiogram (TTE) provided on 
August 29, 2023.