Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Neurology and Neuromuscular Procedures (95885, 
95937, and 95907) provided on September 16, 2021. 
 
You asked the Plan to pay for codes 95885, 95937, and 95907. You say that the medical records support the 
billing of codes 95885, 95937, and 95907 provided on September 16, 2021. The Plan denied your request. The 
Plan says the medical records do not support the billing of codes 95885, 95937, and 95907 provided on 
September 16, 2021. 
 
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 95885 is Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure). The definition of code 95937 is 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The 
definition of code 95907 is Nerve conduction studies; 1-2 studies.  
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 codes 95885, 95937, and 95907. Our reviewer says that the 
medical records do not support the billing of codes 95885, 95937, and 95907 provided on September 16, 2021. 
Our reviewer found in this case none of the codes billed are supported by the records. For code 95937, only 
"train of four" testing was performed. The submitted code should not be used for this service. For codes 95885 
and 95907, a formal nerve conduction study (NCS) was not performed. Rather the member underwent pedicle 
screw testing. This is considered to be a form of triggered Electromyography (EMG). As such it should be 
coded/included in the CPT code for EMG 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 codes 95885, 95937, and 95907 have not been met. Therefore, we decided that 
the Plan does not have to pay for the Neurology and Neuromuscular Procedures (95885, 95937, and 95907) 
provided on September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
December 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the rendering physician is a hospitalist 
with the group and depends upon the hospital staff to verify eligibility and obtain the proper authorization from 
patients insurance companies. 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 subsequent nursing facility care (99308) 
provided on December 23, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 17, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 drug testing provided on February 17, 2022 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided on January 14, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for radiology services (71045) provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care and computer navigation. 
 
You asked the Plan to pre-approve acute inpatient hospital care and computer navigation. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care and 
computer navigation. Our reviewer says that the documentation does not support that the criteria for inpatient 
admission are met in this case. Our physician reviewer found the enrollee total knee surgery may be safely performed as an outpatient or with a 48 hour observational stay. Also, computer navigation is not medically 
needed. The literature does not show better outcomes when it is compared to open surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care and computer navigation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care and computer 
navigation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Diagnostic digital breast tomosynthesis (77062) provided 
on January 11, 2022. 
 
You asked the Plan to pay for code 77062. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of code 77062 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Diagnostic digital breast tomosynthesis (77062) provided on January 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 10, 
2021, to December 13, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs are not 
covered under your 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 pay for the self-administered drugs 
provided from December 10, 2021, to December 13, 2021.  Benefits for the self-administered drugs 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 subsequent nursing care provided on July 5, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services should be covered as you 
disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as there was no reason for them to 
be performed out-of-network as there are in-network providers available to provide the same services. 
 
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 subsequent nursing care provided on July 5, 2021 
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 January 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 28, 2022 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 July 5, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on July 5, 2021 by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (insulin, Amitriptylline, 
Atorvastatin, Budesonide, Celecoxib, Flexeril, Fluticasone, Oretic, Metoprolol, multivitamins, Lyrica, Spiriva, 
Zolpidem, Albuterol, Symbicort, Plavix, Ipratropium, Losartan, Prednisone, and Bactrim) you received from 
February 16, 2022, to February 19, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you used your insulin pump until the 
hospital started to give you insulin when your pump quit working.  You believe these drugs should be covered. 
The Plan denied your request. The Plan says these drugs are not covered under your medical benefits.  
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 pay for the self-administered drugs 
(insulin, Amitriptylline, Atorvastatin, Budesonide, Celecoxib, Flexeril, Fluticasone, Oretic, Metoprolol, 
multivitamins, Lyrica, Spiriva, Zolpidem, Albuterol, Symbicort, Plavix, Ipratropium, Losartan, Prednisone, and 
Bactrim) you received from February 16, 2022, to February 19, 2022.  
 
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on January 26, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an injection. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 an injection provided 
on January 26, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel provided on October 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim provided shows the gene panel was billed with CPT code 81479. 
The Plan did not include any other claims or explanation of benefits to show that the services at issue were 
billed with multiple codes. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for 
the gene panel provided on October 20, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Synvisc One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plan's required drugs would 
likely be less effective and/or likely have adverse effects for you. Without the support of the documentation, 
Synvisc-One is not approved as step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan of the brain provided on 
February 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for CT scan of the brain. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the member's plan excludes coverage for this out-of-network 
service. 
 
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 computed tomography (CT) scan of the brain 
provided on February 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the services should be covered as they were 
medically necessary. The Plan denied your request. The Plan says the services denied correctly as telehealth 
services may only be performed in-network. 
 
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 telehealth visit provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on February 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says there are in-network providers available who could have provided these 
services. 
 
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 physical therapy provided on February 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on November 9, 2021, to 
January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visits. You say that services at this provider have been paid by the 
Plan in the past. The Plan denied your request. The Plan says the services were provided out-of-network and 
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 psychotherapy visits provided on November 9, 
2021, to January 20, 2022, by an out-of-network (OON) provider.