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

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 99024. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99024 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 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 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 70450 
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 70450 billed for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial.The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 25, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump (E0784) and 
supplies (A4238). 
 
You asked the Plan to pre-approve an external ambulatory infusion pump and supplies. 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 continuous subcutaneous insulin infusion (CSII) and 
related drugs/supplies are covered as medically reasonable and necessary in the home setting for the treatment 
of diabetic patients who meet specific criteria. 
 
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 an external ambulatory infusion pump 
and supplies. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
criteria provided state that a pump is not covered if insulinopenia is not demonstrated by c-peptide checks or + 
ab levels. The c-peptide is well above the lln so the criteria are not met. This does not mean that a pump would 
not help the enrollee and that it might be the right therapeutic decision, however, it does mean that coverage 
criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external ambulatory infusion pump and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump 
(E0784) and supplies (A4238).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and testing (99211, 99072, 87426) provided on 
January 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and testing (99211, 99072, 87426) 
provided on January 21, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Durvalumab. 
 
You asked the Plan to pre-approve Durvalumab. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Durvalumab. Our reviewer says that the 
services are medically necessary. Our physician reviewer found Duvalumab is FDA approved as first-line 
treatment of extensive-stage small cell lung cancer (in combination with etoposide and either carboplatin or 
cisplatin) in adults. Small cell of other sites, such as bladder, is treated the same as small cell of the lung. Given 
locally advanced bladder cancer similar to extensive stage small cell lung cancer durvalumab in combination 
with carboplatin and etoposide is reasonable and medically necessary and likely to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durvalumab have been met. Therefore, we decided that the Plan has to pre-
approve Durvalumab.  
 
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 extremity testing (93922) provided on May 31, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the extremity testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 extremity testing (93922) provided on May 31, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6212) provided on May 12, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 wound care supplies (A6196, A6212) provided on 
May 12, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (Q0092, 71046, R0070) provided on February 9, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and prior authorization was not 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 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 x-ray (Q0092, 71046, R0070) provided on 
February 9, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (G0481) provided on February 1, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 laboratory drug testing (G0481) provided on 
February 1, 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 the nursing facility care provided on December 16, 2021, and 
January 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent 
or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on December 16, 
2021, and January 4, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 14, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service May 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of upper or middle spinal facet joint nerves 
using imaging guidance (64633, 64634) provided on March 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the single facet joint. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the destruction of upper or middle spinal facet 
joint nerves using imaging guidance (64633, 64634) provided on March 14, 2022 by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on April 19, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227) provided on 
March 26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 laboratory services (81225, 81226, 81227) 
provided on March 26, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 82565, 80051) provided on July 
6, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 laboratory services (36415, 82565, 80051) 
provided on July 6, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection or mechanical means. 
 
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions using solution injection or 
mechanical means. You say that the services are necessary. The Plan denied your request. The Plan says 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 percutaneous lysis of epidural 
adhesions using solution injection or mechanical means. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is 
insufficient medical literature to support the overall use of this procedure. More research is needed to show 
safety and efficacy of the procedure. The review has determined that the items/services at issue in this case are 
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 percutaneous lysis of epidural adhesions using solution injection or mechanical means have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis 
of epidural adhesions using solution injection or mechanical means.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy coded 45388 provided on February 23, 
2022. 
 
You asked the Plan to pay for the colonoscopy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 45388 is colonoscopy, flexible; with ablation of tumor(s), 
polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed). 
 
We find that CPT code 45388 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) 
(includes pre- and post-dilation and guide wire passage, when performed) was performed. There is a more 
appropriate code to be billed for the services provided. Based on this information, we decided that Medicare 
rules for coverage of the colonoscopy have not been met. Therefore, we decided that the Plan does not have to 
pay for the colonoscopy coded 45388 provided on February 23, 2022.