Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99309 
billed for date of service January 18, 2023. 
 
You asked the Plan to pay for 99309. You say that 99309 should be paid as billed because the diagnosis codes 
reported are valid and supported in the documentation. The Plan denied your request. The Plan says two of the 
billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F06.34 has an Excludes1 note in relation to F03.B18. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for 99309 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services coded as 99309 billed for date of service January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81540 for date of service April 12, 2023. 
 
You asked the Plan to pay for procedure code 81540. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 81540 is Oncology (tumor of unknown origin), mRNA, 
gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor 
into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a 
probability of a predicted main cancer type and subtype. 
 
 
 We find that CPT code 81540 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of Oncology (tumor of unknown origin), mRNA, gene expression profiling by 
real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and 
subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted 
main cancer type and subtype for the billed date of service; therefore, the billed service cannot be supported. 
Based on this information, we decided that Medicare rules for coverage of procedure code 81540 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 81540 for date of service 
April 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Calcipotriene ointment. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Calcipotriene ointment.  Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20704 billed for date of service July 31, 
2023. 
 You asked the Plan to pay for procedure code 20704. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 20704 is bundled into payment for code 27487. 
 
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 20704 
is a column II code to column I code 27487. 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 20704 billed for date of service July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's outpatient cataract surgery services provided on 
May 25, 2023. 
 
You asked the Plan to pay for physician's outpatient cataract surgery services. You say that you cannot afford 
to pay for these 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to pay 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 $1000 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 physician's 
outpatient cataract surgery services was received on May 25, 2023. Therefore, we decided that the Plan does 
not have to pay for physician's outpatient cataract surgery services provided on May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network dermatological procedure 
provided on August 02, 2023. 
 
You asked the Plan to waive the copayment for an in-network dermatological procedure. You say that this was 
to remove lesions from your neck. It should not count as a procedure. 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 $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for an in-network dermatological procedure. 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 an in-network dermatological procedure provided on August 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 21, 
2023.  
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service May 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on April 19, 2023. 
 
You asked the Plan to pay for an x-ray. You say that this should be covered in full. 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 an x-ray provided on 
April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87653, 87798, 87801) provided on 
March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87653, 87798, & 87801 are not supported in the medical record. Specifically, 
multiple unbundled codes were billed for a single panel. 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 (87481, 87653, 87798, 87801) provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87640, 87652, 87798, 87798, 
87799, 87900) provided on March 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87500, 87640, 87652, 87798, 87798, 87799, and 87900 are not supported in the 
medical record. Specifically, multiple unbundled codes were billed for a single panel. 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 (87481, 87500, 87640, 87652, 87798, 87798, 87799, 
87900) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam, and related services provided on July 
03, 2023. 
 
You asked the Plan to pay for a medical eye exam, and related services. You say that the provider was not 
responsible for obtaining 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 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 a medical eye exam, and 
related services provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service May 14, 
2023. 
 You asked the Plan to pay for procedure code 99223. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99223 is bundled into payment for code 12013. 
 
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 99223 
is a column II code to column I code 12013. 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 99223 billed for date of service May 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network acute inpatient stay 
provided on June 02, 2023, to June 09, 2023. 
 
You asked the Plan to reduce the copayment for an out-of-network acute inpatient stay. You say that you feel 
this cost share is too high. You cannot pay this without assistance. 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 $500 
copayment for acute inpatient services.  
You have been asked to pay a $500 copayment for an out-of-network acute inpatient stay. This item/service 
falls within the acute inpatient 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. You have been asked to pay a total of $3500 for the inpatient hospital stay 
($500 copayment x 7 days = $3500). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to reduce the copayment for an out-of-network acute inpatient stay 
provided on June 02, 2023, to June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote interrogation device evaluation (93297, G2066) 
provided on July 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that device checks are submitted monthly. You 
say that some are paid, and other dates of service are randomly denied for no authorization. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 remote interrogation device evaluation (93297, G2066) 
provided on July 16, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 28, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was 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 the laboratory service provided on June 28, 2023, 
by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on May 15, 
2023, to May 16, 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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on May 15, 2023, to May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network injections provided on July 05, 
2023, to July 06, 2023. 
 
You asked the Plan to waive the copayment for in-network injections. You say that you agree with paying for 
the Part B drugs, but you feel you should not have to pay a secondary office 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for in-network injections. This item/service falls within the 
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. The total you owe is $70 ($35 copayment x 2 visits 
= $70). Therefore, we decided that the Plan does not have to waive the copayment for in-network injections 
provided on July 05, 2023, to July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on August 
14, 2023. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you were told this would 
be billed as a primary visit, not a specialist 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 $45 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
Physician/Practitioner services, including doctors officevisits 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 copayment for a specialist office visit provided on August 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided for a foot surgery 
(28297, 28285, 28270) on May 18, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that these services should be covered because 
the primary surgeon was paid. The Plan denied your request. The Plan says a surgical assistant cannot be paid 
for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
for a foot surgery (28297, 28285, 28270) on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed for date of service February 9, 
2023. 
 You asked the Plan to pay for procedure code 88112. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88112 is bundled into payment for code 88173. 
 
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 88112 
is a column II code to column I code 88173. 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 88112 billed for date of service February 9, 
2023.