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

 
We decided that the Plan does not have to pay for the telehealth services provided on December 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
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 G0426 is telehealth consultation, emergency department 
or initial inpatient, typically 50 minutes communicating with the patient via telehealth. We find that CPT code 
G0426 is not supported in the medical record. The records do not indicate how much time was spent with the 
enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the telehealth services provided on December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance provided to the enrollee on February 
10, 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 the provider did not bill as required by coding regulations. 
 
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 the 
services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for fluoroscopic guidance provided to the enrollee on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that only this physician has enough experience for 
the treatment you need. The Plan denied your request. The Plan says that appropriate care is available within 
the Plan. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on April 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-
01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical 
procedure requiring the anesthesia services if performed by the same physician. 
 
We looked at the file and Medicare rules. The file shows that billed procedure code 00732 was performed as 
part of a surgical procedure by the same provider on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services rendered on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit with an out of network provider. 
 
You asked the Plan to pre-approve the physician service. You say that you would like to continue care with 
your Ear, Nose, Throat (ENT) doctor and oncologist. You say that you trust them. You say that you have been experiencing ear pain. You also say that due to delay of authorization you have not been able to go to see your 
specialist office to check if your cancer is back. The Plan denied your request. The Plan says routine oncology 
surveillance can be safely transferred to an in-network oncologist. The Plan also says that there are in-network 
providers available to provide this service. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician service have not been met. Therefore, we decided that the Plan does not have to pre-
approve office visit with an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various non-manipulative chiropractic services received from 
April 6, 2022, to May 5, 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 physical therapy modalities, x-rays, rehabilitation and other incidental services including office 
evaluation and management by chiropractors are not covered by Medicare. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for various non-manipulative chiropractic services received from April 6, 2022, 
to May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 30, 
2020. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. 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 99233 is 1. The MAI value for this code is 2. Review of the file shows that 
this code was already billed for this enrollee for the same date of service under another claim under the same 
billing provider. This means 2 units of this code were billed, exceeding the MUE. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 30, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1843) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary to unload the pressure 
from the joint and to provide stability. The Plan denied your request. The Plan says the records do not 
demonstrate recent injury or surgery, or that instability was found on physical exam. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that there has been a recent injury or surgery to the knee. 
There is no documentation of knee instability on physical examination. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1843) for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an arthrocentesis provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you believe the services 
received were billed incorrectly. The Plan denied your request. The Plan says that the cost share applied is 
correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit an Explanation of Benefits or claim information to 
support the allowed amount of the service billed. This means that we cannot determine the cost you are being 
asked to pay is correct. Therefore, we decided that the Plan has to waive the copayment for an arthrocentesis 
provided on April 20, 2022.  
 
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 procedure code 70470 billed for date of service February 11, 
2022. 
 
You asked the Plan to pay for procedure code 70470. The Plan denied your request. The Plan says payment for 
code 70470 is bundled into payment for code 70496.  
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 70470 
is a column II code to column I code 70496. 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 70470 billed for date of service February 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 92921. The Plan denied your request. The Plan says procedure 
code 92921 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92921 billed for date of service April 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76775 is bundled into payment for code 93976. 
 
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 76775 is a column II code to column I code 93976. 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 76775 billed for date of service May 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 1, 2022, 
through April 1, 2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted, the claim was filed 
accordingly, and the final bill was sent in accordance with Medicare guidelines. You say that this claim should 
be approved. The Plan denied your request. The Plan says an NOA was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, an NOA was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from February 1, 2022, through 
April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services or pay for 
the self-administered drugs provided from May 15, 2022, to May 17, 2022 
 
You asked the Plan to waive the copayment for the outpatient hospital services and to pay for the self-
administered drugs. You say that you feel that you have been overcharged for this hospital stay. The Plan 
denied your request. The Plan says the copayment amount you are being charged for the outpatient hospital 
services is correct. The Plan also says that the self-administered drugs need to be processed under your Part D 
benefit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each Medicare-covered outpatient hospital facility visit under the Outpatient hospital services 
benefit category. The rules also say that Medicare Part B generally does not pay for self-administered drugs.  
 
You have been asked to pay a $225 copayment for the outpatient hospital services. The outpatient hospital 
services provided fall within the Outpatient hospital services 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. 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 
waive the copayment for the outpatient hospital services or pay for the self-administered drugs provided from 
May 15, 2022, to May 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 27, 2021. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this procedure is included in a global 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 99214 is not supported in the medical record. Specifically, the enrollee received 
laparoscopy services on August 23, 2021. This means that this service is included in a global service period and 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0013 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code S0013. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S0013 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0013 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S0013 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0013 billed for date of service May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01215) provided on February 4, 
2022. 
 
You asked the Plan to pay for code 01215. 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. In this case, we have confirmed that code 01215 
is a column II code to column I code 01214 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 anesthesia services (01215) provided on February 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee 
based on medically necessity. The Plan denied your request. The Plan says rules for SNF care have not been 
met. 
 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (49505, 55520) provided on January 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
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 codes 49505 and 55520 is not supported in the medical record. Specifically, the 
requested codes were not billed with the appropriate anatomic modifier. 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 (49505, 55520) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that  The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 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 an office visit provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64624). 
 
You asked the Plan to pre-approve the nerve block. You say that the requested was previously approved. You 
say that the enrollee had to reschedule and the authorization expired. You also say that this is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 nerve block. Our reviewer says that 
there is a lack of adequately designed trials in the peer-reviewed literature concerning the use of genicular 
nerve blocks and radiofrequency ablation as treatments for chronic knee pain. Therefore, the review found that 
the nerve block at issue in this case are not medically reasonable or necessary. Our physician reviewer found 
the requested nerve block has not been researched enough to adequately support that it is beneficial for 
 
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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent (64624).