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

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block (64493).  
You asked the Plan to pre-approve a facet joint block. 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 follows Medicare rules. Medicare rules say that the primary indication of a diagnostic facet joint 
procedure is to diagnose whether the patient has facet syndrome. 
 
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 facet joint block. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found repeating the block a third time is 
not consistent with clinical practice guidelines. After two diagnostic blocks where greater than 80% pain relief 
is achieved, the next step is radiofrequency ablation (RFA). Therefore, the request is deemed not 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 facet joint block have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar/sacral facet joint block (64493).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 30, 2022, to 
September 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. 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 home health services provided on August 30, 
2022, to September 14, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for screening prostate specific antigen tests (G0103) provided July 20, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that this charge is for a PSA test ordered by your 
primary doctor. This was ordered because the doctor was concerned about your health. The Plan denied your 
request. The Plan says that the maximum amount covered by the Plan for this service was paid 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay There is no coinsurance, copayment, or deductible for an 
annual PSA test for Prostate cancer screening exams.  
 
The Plan says you must pay $150.00 for the laboratory service. The Plan says the maximum amount was 
already paid for the services.  However, the Plan has not provided evidence payment was already provided for 
this service. Based on the Plan contract, however, there is no coinsurance, copayment, or deductible for an 
annual PSA test for the laboratory service. Therefore, we decided that the Plan has to pay for screening prostate 
specific antigen tests (G0103) provided July 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of a chest x-ray provided on July 28, 2022. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that multiple exams were provided on this 
date of service. The Plan denied your request. The Plan says that this was denied correctly as a duplicate claim. 
 
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. As noted in the rules cited in the Medicare rules section, a denial for a duplicate 
claim may be appealed. The Plan did not provide actual copies of both claims to review whether the rendering 
provider is the same for both. The provider did show that two different physicians read two separate chest x-ray 
images on the date of service. Based on the documentation available, we find that the denial rationale for these 
services is not substantiated. Therefore, we decided that the Plan has to pay for the interpretation of a chest x-
ray provided on July 28, 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 99053 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 14, 2022, billed with code 77063. 
 
You asked the Plan to pay for the services as billed. You say that the primary code was submitted and paid. As 
such, the claim for the add-on code is eligible for payment. The Plan denied your request. The Plan says that 
this claim has an add-on code without a primary, so it cannot be paid. 
 
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 adequately address the provider's appeal argument in this case. 
This was denied as an add-on code billed without an appropriate primary. However, the provider indicated that 
a claim was submitted and paid with the primary code previously. Identifying information was given. The Plan 
did not refute this argument. The Plan should have verified whether a claim with the primary code was received 
and/or paid. Without this information, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services provided on July 14, 2022, billed with code 77063.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 9, 
2022, to March 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was warranted. The Plan 
denied your request. The Plan says there was no need for this admission. 
 
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was admitted for stress testing. Cardiology consultation described 
the likelihood of cardiac origin of her symptoms "extremely low." The enrollee was diagnosed with 
costochondritis. Based on the presentation of this patient, ruling out of acute coronary syndrome (ACS) early in 
the workup, and stability, it was expected that the patient would require hospital services that would not likely 
cross 2 midnights.  
 
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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 9, 2022, to March 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Portable Gaseous Oxygen Concentrator provided on 
September 06, 2022. 
 
You asked the Plan to pay for a Portable Gaseous Oxygen Concentrator. You say that we were not aware we 
needed prior authorization, please reconsider for medical necessity. 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 a Portable Gaseous 
Oxygen Concentrator provided on September 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 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 76705 
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 76705 billed for date of service October 15, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to March 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022, to 
March 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822, 95886, 95999 provided to the 
enrollee on April 29, 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 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 the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only  
CPT 95886: 
 
Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic 
function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at 
least 5 minutes of passive tilt 
 
CPT 95999: 
 
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 that in terms of CPT 95822, the EEG 
as described falls below the minimum technical standards for performance of an EEG. The limited recording is 
not recognized as being sufficient to serve as a diagnostic/reliable EEG. Nor did the records contain sufficient 
clinical documentation regarding findings to support appropriate reporting of this code. 
 
In terms of CPT 95886, there was no evidence of a nerve conduction study (NCS) having been done. Nor was 
there documentation of the paraspinals being tested in this case. This would not support the use of this specific 
CPT code. 
 
In terms of CPT 95999, the patient had train of four (ToF) testing done. This is considered to be part of the 
CPT code/services done for an electromyography (EMG). The ToF testing is not diagnostic in and of itself and 
is only used as a way to ascertain the reliability of the EMG at that time. 
 
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 codes 95822, 95886, 95999 provided to the enrollee on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on April 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services are experimental/investigational. 
 
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 pay for the laboratory service. Our reviewer says 
that the laboratory service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the service in this case exceeded the enrollees needs for testing. The reviewer found that 
this service is not the standard of care testing as more general inexpensive straightforward testing can give the 
physician the same information. Therefore, the reviewer found that the laboratory service was not medically reasonable or 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the transcutaneous electrical nerve stimulator (TENS) unit rental and 
supply of electrodes provided on September 8, 2022. 
 
You asked the Plan to pay for the TENS unit rental and supplies. You say that this was medically necessary as 
ordered by the treating physical therapist. The Plan denied your request. The Plan says that the proof of 
Delivery did not include an order number or details to corroborate the Delivery Ticket submitted. 
 
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's rationale in this case is not supported. The delivery ticket includes the 
tracking number, which links the delivery ticket to the proof of delivery with the same tracking number. It is 
documented that the TENS unit was received in June 2022, and that the electrodes were delivered in 
accordance with the billed date of service. Therefore, we decided that the Plan has to pay for the transcutaneous 
electrical nerve stimulator (TENS) unit rental and supply of electrodes provided on September 8, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from September 19, 2022, to 
October 15, 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 was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the home health services are not supported in the medical record. Specifically, the claim did not 
contain a required Q code. 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 home health services 
rendered from September 19, 2022, to October 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on July 22, 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 Current Procedural Terminology (CPT) code 95822 26 (1 Unit) remains not supported. 
 
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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 in this case the records did not 
support performance of an EEG that meets the minimum technical standards set-forward by the American 
Clinical Neurophysiology Society (ACNS) for performance of EEG. Rather a 2 channel EEG recording was 
done which is below the minimum technical threshold for this service. Nor is such a limited study considered to be diagnostic for an EEG. In as much this CPT code cannot be said to be supported by the records provided. 
 
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 an electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on 
July 22, 2022.