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

 
We decided that the Plan does not have to pay for neuromonitoring services (95938) provided December 2, 
2020. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 95938 is not supported in the medical record. Specifically, the claim was not billed with 
a valid diagnosis code per Local Coverage Determination (LCD): Somatosensory Testing (L33958). Based on 
this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been 
met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95938) provided 
December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee should be admitted for 
close monitoring. The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
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 admission are met in this case. Our 
physician reviewer found the enrollee is to present for a procedure, which is not on the inpatient only list. There 
is no documentation of uncontrolled co-morbidities pre-procedure. The enrollee should present for the 
procedure as an outpatient. Upon undergoing the procedure, should complications arise or an escalation to a 
more complex procedure be warranted, the enrollee can be converted to inpatient status at that time.  
 
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 acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visit and radiation therapy services 
provided from November 12, 2021, through December 3, 2021. 
 
You asked the Plan to waive the cost share for office visit and radiation therapy services. You say that you met 
your out-of-pocket maximum before these services so they should be covered. The Plan denied your request. 
At the time the claims were received the maximum-out of -pocket had not been met. The Plan says the cost 
share applied is correct.  
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 $30 
copayment for specialist office visits and 20% coinsurance for Medicare-covered therapeutic radiology 
services. 
 
You have been asked to pay a total of $1,224.24 for the office visit and radiation therapy services. Office visits 
fall within the Physician/Practitioner Services benefit category. Radiology testing falls within Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 cost share for office visit and radiation therapy services provided from November 12, 2021, through 
December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and an outpatient clinic visit provided 
on January 19, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for laboratory services and an outpatient clinic visit. You say that the services 
provided were needed for the enrollee's care. The Plan denied your request. The Plan says there is no 
information found that the enrollee was approved to receive services by the non-contracted provider. 
 
  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 and an outpatient clinic visit 
provided on January 19, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 20930, 20936, and 20939 
provided on August 24, 2021. 
 You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare billing 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. 
 
We find that CPT code 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT code 20930 and 20936 are both not separately payable. In addition, we have confirmed that 
code 20939 is a type I add-on code that has not been billed with the required primary procedure code. This 
code cannot be paid as billed. Based on the claim submitted, Medicare billing criteria have not been met. Based 
on this information, we decided that Medicare rules for coverage of the medical services as billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 20930, 
20936, and 20939 provided on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on 
December 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says assistant at surgery may not be paid for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 63650. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services provided to the enrollee on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings identified with code 
A6532. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings identified 
with code A6532.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (A4930) used September 21, 2021. 
 
You asked the Plan to pay for the medical supplies. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code A4930 has a Status Indicator of N on the Physician Fee Schedule. This means that CPT 
code A4930 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for medical supplies (A4930) used September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
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 pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is an 89-year-old female being treated for spondylosis without 
myelopathy or radiculopathy; other intervertebral disc degeneration of the lumbar region; and low back pain. 
She presented via telehealth, with low back pain. She rarely has any leg symptoms and will occasionally get 
numbness. Height is 5 feet 5 inches, weight is 93 pounds, and body mass index is 15.48 kg/m2. Exam reveals 
stooped posture. 
 
However, in this case, there were/are multiple plausible pathologic sources of significant pain generation. The 
non-radiating midline back pain is non-specific to any pathologic entities. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested Intracept 
intraosseous nerve ablation at L2 through S1, in this case, is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
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 a transthoracic echocardiogram. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no supportive evidence for the medical necessity of a transthoracic 
echocardiogram in this enrollees clinical management. 
 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 transthoracic echocardiogram. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says laboratory testing related to treatment of 
ESRD is bundled into dialysis services and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department evaluation and management 
service provided on November 9, 2021. 
 
You asked the Plan to pay for emergency visit. You say that the coding department has reviewed the level of 
emergency evaluation and concluded that this coding was done the best. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the Plan paid for one unit of 99285 and a 
second unit is 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 99285 is emergency department visit for the evaluation 
and management of a patient. 
 
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 emergency visit. Our reviewer says that a second unit of this 
code does not meet criteria for payment. 
 Our reviewer found the medical record does not support additional services performed on this date. Code 
99285 would be reported with one unit, the documentation does not support 2 evaluation and management 
services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency visit have not been met. Therefore, we decided that the Plan does 
not have to pay for an emergency department evaluation and management service provided on November 9, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need to get to your 
appointments. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
14, 2021, to February 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9123 is not valid for Medicare purposes. Home health services should be billed with G and Q codes. 
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 provided to the enrollee from 
February 14, 2021, to February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. 
 The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
genetic testing. We found no exception that would require the Plan to pay for the genetic testing. The records 
provided for review do not show that the genetic testing was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on January 26, 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 implantable pump refill and maintenance provided on 
February 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the implantable pump refill and maintenance. You say that you are requesting 
reconsideration stating the wrong insurance was provided. The Plan denied your request. The Plan says the out-
of-network services were not authorized.  
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 implantable pump refill and maintenance 
provided on February 2, 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 nursing facility care provided on November 9, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for nursing facility care. You say that services were provided prior to obtaining 
authorization to avoid delay in care. The Plan denied your request. The Plan says services were not authorized 
by the Plan and you were aware of the need for pre-authorization. 
 
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 nursing facility care provided on November 9, 
2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cystoscopy and treatment provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for cystoscopy and treatment. You say that you feel that the 
copayment is not correct. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $200 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay $200 copayment for cystoscopy and treatment. Cystoscopy and treatment falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 cystoscopy and treatment 
provided on February 1, 2022.