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

 
We decided that the Plan does not have to pay for procedure code P9603 provided on August 4, 2023. 
 
You asked the Plan to pay for procedure code P9603. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code P9603 have been met. 
In this case, there were no medical records provided to support the billing of procedure code P9603 for the 
August 4, 2023, date of service. Therefore, we decided that the Plan does not have to pay for procedure code 
P9603 provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visits (99205, 99215) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you want to go to your old pain management 
provider because the doctor knows your medical history. 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 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 
the outpatient office visits (99205, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with codes A4221, A4223, and A4305 for 
July 20, 2023, to July 26, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that disposable drug delivery systems are non-covered. 
 
We looked at the file and Medicare rules. The services at issue are supplies for a disposable drug delivery 
system. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the supplies billed with codes A4221, A4223, and A4305 for July 20, 2023, to July 26, 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 June 
29, 2023, to July 03, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you never had such a 
high copay for hospitalization and you dont understand why your copay would be so high. 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 $200 
copayment for inpatient hospital care.  
You have been asked to pay a $200 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 $800 for the inpatient hospital stay ($200 copayment 
x 4 days = $800). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on June 29, 2023, to July 
03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on September 12, 
2023. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel that the plan should pay for 
the services. 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 $140 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $140 copayment for the CT scan. 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 $125.95. Therefore, we decided that the Plan does not have to waive the copayment 
for the CT scan provided on September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87529) provided on May 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that these 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. 
 
In this case, the CPT Code Manual definition of code 87529 is Infectious agent detection by nucleic acid (DNA 
or RNA); Herpes simplex virus, amplified probe technique. 
 
We find that CPT code 87529 is not supported in the medical record. Specifically, no results were provided for 
this test. 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 lab services (87529) provided on May 
30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with biopsy 
provided on August 07, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy with biopsy. You say that you had 
colon cancer and needed this done, you should not have a copayment. 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 $200 
copayment for outpatient hospital services. 
 
You have been asked to pay a $200 copayment for a diagnostic colonoscopy with biopsy. This item/service 
falls within the outpatient hospital 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 copayment 
for a diagnostic colonoscopy with biopsy provided on August 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided on July 
22, 2023, and August 5, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you should not have to 
pay the billed amount. 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 your cost sharing for 
Medicare oxygen equipment coverage is 20% coinsurance every month.  
 
  You have been asked to pay a total of 33.17 for the oxygen equipment.  
 
The total amount allowed to be billed for oxygen equipment provided on July 22, 2023, was $123.75. You have 
been asked to pay an $24.75 coinsurance for this equipment, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for oxygen equipment provided on August 5, 2023, was $42.09. You 
have been asked to pay an $8.42 coinsurance for this equipment, which is 20% of the total allowed amount. 
 
These items/services fall 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 the oxygen equipment provided on July 22, 2023, and 
August 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service from June 
21, 2023, to June 22, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the code at issue is not supported. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the code definition is time-based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99233 billed for dates of service from June 21, 2023, to June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on September 18, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that kindly review and reprocess the claim for payment. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided on 
September 18, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 7, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, infectious agent detection, 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 the laboratory services rendered on September 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) scan showing only modic endplate changes 
without facet degenerative joint disorder (DJD) or stenosis. The cause of the enrollee's pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for September 2, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately paid. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 96372 has an OPPS status indicator of Q1(s) 
and was billed with code 99284, which has an OPPS status indicator of V. Code 96372 is not separately 
payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the Plan does 
not have to pay for procedure code 96372 billed for September 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing was not billed correctly. 
 
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 services rendered on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for validity testing. You say that you have billed the service at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 validity testing 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 validity testing (83789) billed for date of service July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for November 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed with the incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that code 99203 was billed with a POS code for an 
emergency room, not an office setting. Therefore, we decided that the Plan does not have to pay for procedure 
code 99203 billed for November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 16, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that 99232 should be paid because it was billed 
by a multi-specialty group where multiple providers may see the same enrollee for different conditions. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99222. 
 
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 confirmed that both 99232 and 99222 were billed for the same date of service and were performed by the same rendering provider. We also 
confirmed that code 99232 is a column two code to column one code 99222 with a modifier indicator of 0. The 
column two 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 code 99232 billed for date of 
service April 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laparoscopy surgical repair of a hernia 
provided on August 24, 2023, to August 26, 2023. 
 
You asked the Plan to waive the copayment for the laparoscopy surgical repair of a hernia. You say that you do 
not agree with the denial of medical coverage for admission to an inpatient level of care. 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 $400 
copayment for surgery services - outpatient hospital. 
 
You have been asked to pay a $400 copayment for the laparoscopy surgical repair of a hernia. This item/service 
falls within the surgery services - outpatient hospital 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 laparoscopy surgical repair of a hernia provided on August 24, 2023, to August 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0676 and 
E0677 and half leg appliance coded E0673 billed for December 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675 and E0677. These 
services are denied by Medicare as not medically necessary. Given that the E0675 and E0677 PCDs are not 
covered, the half leg appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device (PCD) coded E0676 and E0677 and half leg 
appliance coded E0673 billed for December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 laboratory services 
provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94640 billed for September 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 94640 has an OPPS status indicator of Q1(s) 
and was billed with code 99284, which has an OPPS status indicator of V. Code 94640 is not separately 
payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the Plan does 
not have to pay for procedure code 94640 billed for September 3, 2023.