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

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on November 3, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on November 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the 
out-of-network (OON) provider on December 13, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) 
provider on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) providers on June 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 providers in this case are not network providers with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) providers on June 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95957-26, 95908-26, and 95886-26 billed 
for date of service December 28, 2020. 
 
You asked the Plan to pay for procedure codes 95957-26, 95908-26, and 95886-26. You say that you have 
submitted medical records to support payment of these codes. The Plan denied your request. The Plan says the 
medical records do not support payment for these codes. 
 
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 95886 is Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The definition of code 95908 is Nerve conduction 
studies; 3-4 studies, and the definition of code 95957 is Digital analysis of electroencephalogram (EEG) (e.g., 
for epileptic spike analysis).  
We asked our coder 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 procedure codes 95957-26, 95908-26, and 95886-26. Our 
reviewer says that these codes are not supported in the medical record. Our reviewer found for code 95886, the 
technical report does not include documentation to support this code description, as nerve conduction studies 
cannot be verified, which is a part of EEG procedure reported. For code 95908, the technical report does not 
include nerve conduction studies measuring amplitude and latency/velocity.  The report cannot be cited 
because this procedure is not documented. The doctor also found that for code 95957, the technical report 
includes a baseline EEG, but no other additional tests were documented.  Code 95957 is the incorrect procedure 
code to report for baseline EEG.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95957-26, 95908-26, and 95886-26 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95957-26, 95908-26, and 95886-
26 billed for date of service December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final 
restoration) (D3310). 
 
You asked the Plan to pre-approve a root canal. You say that you are in pain and your dentist advised you need 
a root canal as soon as possible. The Plan denied your request. The Plan says this service is not covered under 
your 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 pre-approve 
endodontic therapy, anterior tooth (excluding final restoration) (D3310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on October 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that it was medically necessary to treat the 
enrollee and service was provided in good faith. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no prior authorization obtained from the enrollee's 
primary care physician. 
 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 clinic visit provided on October 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0184T-22 billed for date of service November 9, 2021. 
 
You asked the Plan to pay for procedure code 0184T-22. You say that you have submitted medical records to 
support payment of this service. The Plan denied your request. The Plan says that the modifier billed is not 
valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We 
asked our coder 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 procedure code 0184T-22. Our reviewer says that this service was 
billed correctly. Our reviewer found you reported services with modifier 22.  After careful review of Medicare 
rules, no guideline was found that code 0184T would not be reported with modifier 22.  The operative report 
clearly documents difficulty, and increased services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 0184T-22 have been met. Therefore, we decided that the Plan 
has to pay for procedure code 0184T-22 billed for date of service November 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from September 24, 2021, to 
November 23, 2021, by an OON provider. 
 
You asked the Plan to pay for the office visits. You say that your provider is in network. The Plan denied your 
request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 office visits provided from September 24, 
2021, to November 23, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on July 14, 
2021. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that the injection was at the 
provider's office, not in a hospital or clinical setting. You also say you have had injections done previously and 
there never was a charge for a specialty room. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for in-network outpatient surgery at an ambulatory surgical center.  
 An arthrocentesis is considered a surgical procedure. The record shows the claim was processed correctly. You 
have been asked to pay a $150 copayment for an arthrocentesis. An arthrocentesis falls within the Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 arthrocentesis provided 
on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82310, 82728, 83540, 83550, 83970, and 
84100) billed for date of service October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 
In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.   According to Medicare rules, these lab services are not separately payable as billed. Therefore, we decided that 
the Plan does not have to pay for lab services (codes 82310, 82728, 83540, 83550, 83970, and 84100) billed for 
date of service October 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 16, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the claim reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from the enrollee's primary care physician or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on June 16, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82728, 83540, and 8550) billed for date 
of service October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 
 
 In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.  According to Medicare rules, these lab 
services are not separately payable as billed. Therefore, we decided that the Plan does not have to pay for lab 
services (codes 82728, 83540, and 8550) billed for date of service October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metaxalone tablets. 
 
You asked the Plan to pre-approve Metaxalone tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Metaxalone tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Metaxalone tablets.  
 Benefits for Metaxalone tablets 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 lab services billed with code 87361 for date of service 
December 6, 2021. 
 
You asked the Plan to pay for code 87361. You say that this test was provided for a covered diagnosis, so it 
should be paid. The Plan denied your request. The Plan says this test was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of multiplex polymerase chain reaction 
(PCR) respiratory viral panels is limited. Panels of 3-5 pathogens are covered under limited circumstances. 
Specifically, the test must be ordered either in a healthcare setting that is equipped to care for and routinely 
does care for critically ill patients, or it must be ordered by an infectious disease specialist, unless an infectious 
disease specialist is not available. 
 
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 code 87361. Our reviewer says that this lab 
service is not supported. Our physician reviewer found the record indicates that the enrollee underwent a 
diagnostic test. The record provided does not indicate that the test was ordered either in a healthcare setting that 
is equipped to care for and routinely does care for critically ill patients. The record does not indicate that the 
requested test was ordered by an infectious disease specialist, or that an infectious disease specialist is not 
available. The record provided is insufficient to support the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87361 have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services billed with code 87361 for date of service December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on 
September 23, 2021. 
 
You asked the Plan to pay for the CGM. You say that the patient's primary care doctor ordered this item. The 
Plan denied your request. The Plan says this item is not supported by the referring physician exam notes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that this CGM 
does not meet criteria. Our physician reviewer found although this patient has type 2 diabetes, the records 
provided did not clearly show recent and regular usage of a blood glucose meeting.  It is documented that the 
patient uses insulin 30-5 times daily, but it is not clearly described in the provided documentation that the 
patient required frequent daily adjustments in insulin dosing based on CGM readings.  
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pay for the continuous glucose monitor (CGM) provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the 
requested epidural steroid injection. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided for review to 
determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pre-approve 
an epidural steroid injection (62323).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four separate units of code 76441-26 you billed for date of 
service December 6, 2021. 
 
You asked the Plan to pay for four units of 76441-26. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says it has already paid for one unit each of 76641-26 (RT) 
and 76441-26 (LT) billed for this date of service.  You have billed a duplicate second billing of these codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that four separate units of code 76441-26 are not supported in the medical record. The medical record 
only supports 2 units of CPT code 76441-26, and those two were already paid. Based on this information, we 
decided that Medicare rules for coverage of four units of 76441-26 have not been met. Therefore, we decided 
that the Plan does not have to pay for four separate units of code 76441-26 you billed for date of service 
December 6, 2021.