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

 
We decided that the Plan does not have to pay for procedure code 64451 billed for date of service June 29, 
2022. 
 You asked the Plan to pay for procedure code 64451. You say that you do not believe the denial is appropriate 
and you have coded this claim correctly. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64451 is 2. The MAI value for this code is 2. You billed a total of 6 units 
of this code (3 units on the left side and 3 on the right), exceeding the MUE. Further, we understand your 
argument that your facility is an ASC and you are unable to bill the 50 modifier to indicate the procedure was 
done bilaterally. However, under Medicare rules, in an ASC, the MUE value is doubled when the service is 
billed bilaterally.  In this case, that would make the MUE value 4 units instead of 2.  However, you have still 
billed units in excess of the MUE by billing a total of 6 units. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64451 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64451 billed for date of service June 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 rendered on May 27, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular 
diagnostic procedure." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found per coding guidelines, there needs to 
be a code description. This was not given; therefore, the use of CPT 95999 is not supported. 
 
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 procedure code 95999 rendered on May 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2068) provided on October 17, 
2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this provider is not eligible for payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, Critical Access Hospitals, and Free-
Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. The billing provider is an individual provider and not a hospital or 
treatment facility. Based on this information, we decided that Medicare rules for coverage of the opioid 
treatment services have not been met. Therefore, we decided that the Plan does not have to pay for opioid 
treatment services (G2068) provided on October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ureterolysis, with or without repositioning of ureter for 
retroperitoneal fibrosis rendered on August 1, 2022. 
 
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 this is part of the primary procedure and ineligible for separate pay. 
 
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 50715 is "Ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that ureterolysis, with or without 
repositioning of ureter for retroperitoneal fibrosis (CPT 50715) was not done on 8/1/22. The records do not 
show that the enrollee had retroperitoneal fibrosis. The mobilization of the ureter to expose the lower spine is 
considered a component of the anterior lumbar diskectomy and arthrodesis.  
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 ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis rendered on 
August 1, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Spravato. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this will not be covered if the patient has a history of substance or alcohol use 
disorder. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 services. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that the enrollee has been 
tried on multiple therapies. It is noted that the enrollee had a score of 22 on the Hamilton Depression Scale. 
This patient has been taking Lamictal, Abilify, Wellbutrin, Lexapro and Vyvanse with poor success. This 
patient does have a history of alcohol use and had been in treatment which falls into the criteria for use of 
Spravato/Esketamine. Based on a review of the records provided this patient does meet the criteria for the use 
of Spravato/Esketamine for the treatment of major depressive disorder, recurrent, severe without psychotic 
features. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
Spravato.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on December 13, 2022. 
 
You asked the Plan to pay for labratory services. You say that the beneficiary is in a facility and cannot go to a 
lab to get bloodwork done. They do not have a choice who preforms this service. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for labratory services 
provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical x-rays (D0220) and a limited oral 
evaluation-problem focused (D0140) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you didn't know you exhausted your benefits. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 1, 2022 for the 
x-rays (D0220) and October 17, 2022 for the oral evaluation (D0140). Therefore, we decided that the Plan does 
not have to pay for intraoral-periapical x-rays (D0220) and a limited oral evaluation-problem focused (D0140) 
provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging guidance cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it seems as though IGRT is simply being used as routine practice, as there does not seem to be any 
exceptional circumstances with this patient necessitating the need for IGRT. IGRT is not an accepted standard 
of care for routine use in the palliative treatment of bone metastases. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion/pillow/wedge, any shape or size, 
includes all components and accessories (E0190). 
 
You asked the Plan to pre-approve a positioning pillow. You say that you need this pillow for after your eye 
procedure. You say that the referral was faxed over while you were at the office. You also say that you have 
pain along your neck and back from your previous surgery. The Plan denied your request. The Plan says the 
provider did not submit a signed order for the item at issue in this case.  
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 corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a positioning pillow have been met. 
Specifically, the file does not include a signed order from the physician for the item at issue in this case. 
Without a physician order, it cannot be determined why the requested item is needed. Therefore, we decided 
that the Plan does not have to pre-approve a positioning cushion/pillow/wedge, any shape or size, includes all 
components and accessories (E0190).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 24, 2021 to May 
31, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the DRG downgrade. The Plan denied your request. The Plan says without a proper note and clinical 
support, N17.0 should not be coded. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 377. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that based on the medical records provided the diagnosis code N17.0 is not supported. The patient presented 
with chest pain and hematemesis; his creatinine level was 0.86 at presentation and remained stable in this range 
throughout the hospital stay. DRG 377 for acute pancreatitis is not supported. Despite presenting with chest 
and epigastric pain, for most of the hospital stay the patient had no abdominal pain and his abdominal exam 
was "soft and non-tender." Computed tomography imaging of the abdomen reported an "unremarkable" 
pancreas. Records provided to this reviewer do not clearly show that the patient's lipase level of 121 on 
05/24/2021 was elevated for that laboratory to indicate acute pancreatitis.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 24, 2021 to May 31, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an injection, anesthetic agent; lumbar or thoracic (paravertebral 
sympathetic) (64520). 
 
You asked the Plan to pre-approve a lumbar sympathetic block. You say that the requested injection is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested injection is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a lumbar sympathetic block. Our 
reviewer says that the requested lumbar sympathetic block is considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided documentation indicates that the enrollee's lower 
extremity pain is from vascular claudication. The reviewer found that the purpose of this block is to diagnosis 
whether there is sympathetic vasoconstriction present. Therefore, the reviewer found that the requested block is 
medically reasonable and 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 a lumbar sympathetic block have been met. Therefore, we decided that the Plan 
has to pre-approve an injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) (64520).  
 
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 waive the coinsurance for durable medical equipment (DME) 
provided on January 28, 2022, to March 28, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on January 28, 2022, to March 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services provided on November 12, 2022. 
 
You asked the Plan to pay for therapeutic services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for therapeutic services 
provided on November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 07, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the vertebral axial decompression (S9090) 
provided from March 29, 2022, through June 3, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the vertebral axial decompression (S9090) provided 
from March 29, 2022, through June 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room visit 
provided on September 21, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room visit. You say that this 
emergency room visit should be a continuation of your initial visit. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for in-network emergency care.  
 
You have been asked to pay a $50 copayment for an emergency room visit. This item/service falls within the 
in-network emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network emergency room visit provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for free standing clinic visit provided on September 16, 2022. 
 
You asked the Plan to pay for free standing clinic visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for free standing clinic visit 
provided on September 16, 2022.