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

 
We decided that the Plan does not have to pay for the X-ray exam of the pelvis (72170) provided on October 
11, 2021. 
 
You asked the Plan to pay for the X-ray exam of the pelvis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the documentation does not support 
payment for an additional unit of code 72170 beyond what was already paid. 
 
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 72170 is radiologic examination, pelvis; 1 or 2 views. 
 
We find that CPT code 72170 is not supported in the medical record. Specifically, the medical records provided 
do not indicate an additional X-ray of the pelvis beyond what the Plan has already paid. Based on this 
information, we decided that Medicare rules for coverage of the X-ray exam of the pelvis have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the pelvis (72170) provided on 
October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from  
January 6, 2022, through January 7, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
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 provided 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 
(A9270) provided from January 6, 2022, through January 7, 2022.  Benefits for these items 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection and diagnostic radiology services provided on 
February 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an injection and diagnostic radiology services. 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 and diagnostic radiology services 
provided on February 15, 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 subcutaneous infusion for therapy or prophylaxis (specify 
substance or drug) (96371) Injection, triamcinolone acetonide, not otherwise specified, 10 mg (J3301) provided 
on January 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the infusion services. You say that you were in Denver for your husbands lung 
transplant and needed to keep up on the osteoporosis treatment. You were not aware that the doctor was out of 
network as you were referred by your doctor. It was important you received your shot. 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 subcutaneous infusion for therapy or prophylaxis 
(specify substance or drug) (96371) Injection, triamcinolone acetonide, not otherwise specified, 10 mg (J3301) 
provided on January 7, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology services. You say that you have done everything the in-
network providers have asked you to do, and you still cannot see out of your right eye. The Plan denied your 
request. The Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the ophthalmology services. We found no exception that would require the Plan to 
pre-approve the ophthalmology services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on January 20, 2022. 
 
You asked the Plan to pay for the services. You say that fadfdfas The Plan denied your request. The Plan says 
this service was billed incorrectly. 
 
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 payment for CPT code 85060 is not supported in the medical record. Specifically, the services 
were billed with an outpatient hospital place of service. Code 85060 is assigned a PC/TC indicator of 8. This 
means that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 
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 (85060) provided on January 20, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an x-ray received on December 8, 2021. 
 
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 that routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
The services you are asking the Plan to pay for are not routine foot care services. The denied service is an x-ray 
of the foot. Based on this information, we decided that Medicare rules for coverage of the services have been 
met. Therefore, we decided that the Plan has to pay for an x-ray received on December 8, 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 visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office the office visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for these items/serv the office visit. The 
records provided for review do not show that office visit was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the 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 pre-approve peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that peripheral nerve stimulator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
LCD coverage criteria 
 
The Plan follows Medicare 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 pre-approve peripheral nerve stimulator. Our 
reviewer says that peripheral nerve stimulator is not medically necessary. Our physician reviewer found the 
provided records do not document a formal psychological screening by a mental health professional (related to 
her chronic pain and the proposed peripheral nerve stimulator) or a successful stimulation trial with greater 
than or equal to 50% reduction in pain intensity before permanent implantation as required by the LCD.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a lightweight wheelchair provided on December 1, 2021. 
 
You asked the Plan to pay for lightweight wheelchair. You say that your doctor is fully aware that you cannot 
walk and gave you a prescription for insurance purposes. The Plan denied your request. The Plan says that the 
denial of payment for this item is correct, because you do not meet Medicare criteria for a lightweight 
wheelchair. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for lightweight wheelchair by a contract provider. The file does not show that the Plan 
provided notice that lightweight wheelchair would not be covered. Under Medicare rules, this means 
lightweight wheelchair is considered approved by the Plan. Therefore, we decided that the Plan has to pay for a 
lightweight wheelchair provided on December 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensor/flash glucose monitoring 
system (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the enrollee would benefit 
from the CGM to help control blood sugars. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria as he is not currently on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 sensor/flash glucose 
monitoring system (K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the femoral nerve injection (64447) provided on December 
7, 2021. 
 
You asked the Plan to pay for the femoral nerve injection (64447). You say that the records document the nerve 
block guidance for this procedure. You say that these services were rendered during the same procedure and 
CPT code 64447 should be paid since 01402 was paid. The Plan denied your request. The Plan says CPT code 
64447 is included in CPT code 01402. 
 
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 64447 is a column II code to column I code 01402; however, 64447 
was billed with a modifier.  
 
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 the femoral nerve injection (64447). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
medical record does not include documentation to confirm the anesthetic agent was performed for post 
operative pain management not anesthesia services. Therefore, this procedure cannot be confirmed. 
 
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 femoral nerve injection (64447) have not been met. Therefore, we decided 
that the Plan does not have to pay for the femoral nerve injection (64447) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on December 15, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the billed charges. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the pharmacogenomics gene panel was billed with multiple codes. If a single procedure is 
performed, only code with one unit of service may be reported for the procedure. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomics testing provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01992) provided on October 25, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the services at issue are included in another billed 
code. 
 
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 01992 is "Anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position." 
 
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 anesthesia services. Our reviewer says that the services at 
issue do not meet criteria for payment. Our reviewer found that, when reporting a procedure that normally 
would not require anesthesia, documentation must include medical necessity. In this case, the medical record 
does not document the reason anesthesia was given for nerve block injection.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia services (01992) provided on October 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after June 30, 2022. 
 
You asked the Plan to pre-approve SNF care after June 30, 2022. You say that the continued admission to a 
SNF is medically necessary The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after June 30, 2022. Our 
reviewer says that you do not meet the Medicare criteria for continued SNF care. Our physician reviewer found 
continued daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after June 30, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99051) provided on November 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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 99051 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99051 is not separately payable. 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 
(99051) provided on November 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99284) provided on November 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 99284 
is a column II code to column I code 99285. 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 the services (99284) provided on November 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service January 31, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for 
code 74019.  You billed with a 76 modifier, but this modifier is not an allowable modifier permitting separate 
payment.  
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 74018 
is a column II code to column I code 74019. 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 74018 billed for date of service January 31, 
2022.