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

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on 
March 4, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99152 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; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for the moderate sedation services coded 99152 provided on March 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided from December 4, 2019 
to March 4, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided from December 4, 2019 to 
March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for the 
services is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 6, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an autograft for spinal surgery (20936) provided on February 
18, 2020. 
 
You asked the Plan to pay for the autograft. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 20936 has a status indicator of B which 
means that payment for this service is always bundled into the payment for the primary service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20936 is not supported in the record. Specifically, per Medicare guidance, CPT code 
20936 has a status indicator of B. This means that payment for 20936 is always bundled into the payment for 
another service. Based on this information, we decided that Medicare rules for coverage of the autograft have 
not been met. Therefore, we decided that the Plan does not have to pay for an autograft for spinal surgery 
(20936) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 30, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic and two retainer crowns provided on May 12, 
2020. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that it was necessary to have your teeth 
repaired. You also say that the provider has a contract with the insurance company, and should expect equal 
payments. The Plan denied your request. The Plan says these services are not covered. 
 
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 the pontic 
and two retainer crowns provided on May 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided on September 22, 2019. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration because 
this service was medically necessary and you were not aware this was not a covered benefit. The Plan denied 
your request. The Plan says you did not meet criteria for non-emergent transportation. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the transportation services. Our reviewer 
says that the documentation does not support that stretcher van or wheelchair van would have been 
contraindicated for you. The documentation does not support that you required the expertise and specialized 
equipment in an ambulance. You had no unstable condition warranting these services Our physician reviewer 
found the documentation does not support that the ambulance transport was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transportation services have not been met. Therefore, we decided that the 
Plan does not have to pay for transportation services provided on September 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 9, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 remains 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to, GC/MS (anytype, single or tandem) and LC/MS 
(any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic 
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in 
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no valid physician 
order to verify these services. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services 
provided to the enrollee on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be reported with CPT 81479 
and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested CGP testing was billed with multiple CPT codes. Per 
the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. 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 lab services provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of the heart lung machine provided 
December 18, 2019. 
 
You asked the Plan to pay for assembly and operation of the heart lung machine. You say that these charges are 
for the perfusionist that setup and operated the heart-lung machine. The perfusionist is required to be in the 
operating room during the length of the procedure. The Plan denied your request. The Plan says the enrollee 
received the services in the facility during inpatient hospitalization, and payment for this service would be 
included in the part-A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. In this case, the facility or hospital must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers. The enrollee was an inpatient, therefore all services provided to the enrollee will be paid 
under the global facility claim. Payment for the perfusionist service would have been included under the 
facility claim. Payment to the perfusionist for this service is the responsibility of the facility or hospital. Based 
on this information, we decided that Medicare rules for coverage of assembly and operation of the heart lung 
machine have not been met. Therefore, we decided that the Plan does not have to pay for assembly and 
operation of the heart lung machine provided December 18, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit (99285) electrocardiogram, 
routine ECG with at least 12-leads; interpretation and report only (93010) provided September 22, 2019. 
 
You asked the Plan to pay for emergency services. You say that given the emergent nature of the admission 
and the services rendered, you request re-examination of the claim below and reprocess the charges denied for 
the date. The Plan denied your request. The Plan says the benefit for this service is included in the 
payment/allowance for another service/procedure that has already been adjudicated. 
 
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,  CPT code 99285 and 93010 is the column II code to the more comprehensive column I code 
29125 but a modifier is allowed in order to differentiate between the services provided. Per review of medical 
records, 99285 and 93010 is supported as separate and distinct from procedure code 29125 that was performed. 
However, an appropriate modifier to represent the services as separate and distinct was not used. Based on this 
information, we decided that Medicare rules for coverage of emergency services have not been met. Therefore, 
we decided that the Plan does not have to pay for emergency department visit (99285) electrocardiogram, 
routine ECG with at least 12-leads; interpretation and report only (93010) provided September 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement 
grafts (D7953) and analgesia (D9230) provided on April 30, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration (D4266), bone replacement grafts (D7953) and 
analgesia (D9230). You say that the work is necessary for your health and wellbeing. You say that services 
should be covered by insurance for comfort, medical and financial justifications. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
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 the 
guided tissue regeneration (D4266), bone replacement grafts (D7953) and analgesia (D9230) provided on April 
30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to 
verify eligibility and obtain proper 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on March 23, 2020 by an out of network 
(OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had in 
April 3, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't have to pay this 
copayment.  You say that you had to go to the ER for care since your doctor's office was closed due to COVID-
19. The Plan denied your request. The Plan says you were charged this copayment 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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This amount applies regardless of the reason why you 
went to the ER. 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 emergency room (ER) visit 
you had in April 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
had on April 23, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that this MRI was needed to determine if you 
needed surgery, so it should be covered in full. The Plan denied your request. The Plan says that it covered by 
MRI, but you owe this copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for diagnostic radiology services other than CT scans.  
 
You have been asked to pay a $225 copayment for the MRI. The MRI is a non-CT diagnostic radiology 
service. 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 magnetic resonance imaging (MRI) you had 
on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 95937) provided on February 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 95937 is ?Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method?. 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 95937 is not supported by the records provided. Our coding reviewer found that train of four was 
performed, however, this procedure would not be billed with CPT 95937. Train of four testing does not fit the 
criteria set by CMS and insurance carriers for CPT 95937. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 95937) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is up to the hospital staff to verify 
eligibility and to obtained prior 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 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. 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 medical services provided on January 6, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on April 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not payable for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
38525. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgeon services provided on April 8, 2020.