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

 
We decided that the Plan does not have to pay for code 99285, defined as emergency department visit for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making, and code 99053, defined as services provided between 10:00 PM 
and 8:00 AM at 24-hour facility, in addition to basic service, performed on June 7, 2023.  
You asked the Plan to pay for 99285 and 99053. You say that 99285 and 99053 should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says 99285 is denied 
because it is not supported in the medical record and 99053 is considered bundled and is not separately 
payable. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate procedure code. 
 
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 99285. Our reviewer says that code 99285 is 
not supported in the documentation. Our physician reviewer found the provided records document an 86-year-
old enrollee who presented with body aches that started about 2 weeks prior. History, examination, laboratory 
testing, and radiographic testing were performed with a final diagnosis of myalgia. The enrollee was treated 
with ketorolac and discharged to home to follow-up with their primary care provider. Provided records in this 
case do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive 
amount and complexity of data reviewed, and high risk of complication, as is required for code 99285.  
 
 
We looked at this physician's review, the file, and Medicare rules. With regards to code 99053, we find that 
99053 has a status indicator of B on the Physician Fee Schedule. This means that 99053 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of 99285 and 99053 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 99285, defined as emergency 
department visit for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making, and code 99053, defined as services provided 
between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service, performed on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a four or more surface resin-based composite (D2335) 
provided on August 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a four or more surface resin-based composite 
(D2335) provided on August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for diagnostic testing you received on January 26, 2023. 
 
You asked the Plan to pay more for the diagnostic testing. You say that you are being billed by the facility for 
these services. The Plan denied your request. The Plan says it has paid this provider the Medicare-allowed 
amount for the services rendered.  No further payment is due. 
 
The Plan must follow Medicare rules. Medicare rules say that for services provided by providers who 
participate with Medicare, Medicare Health Plans cannot be obligated to pay more than the Medicare-allowed 
amount for services.  No balance billing is paid by either the Plan or the enrollee. 
 
In this case, you received these services at a facility that participates in Medicare.  As a result, that facility must 
accept the Medicare-allowed rate for the services provided.  The Plan has already paid the Medicare-allowed 
amount for the services rendered.  The Plan cannot be obligated to pay any more towards this claim. 
 
However, you should not be billed by this provider either.  This provider is required to accept Medicare-
allowed rates.  You have the right to go to the provider and request that they stop balance billing you because 
you are in a Medicare health plan.  As a Medicare-participating provider, they are not allowed to seek 
additional payment from you.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pay 
more for diagnostic testing you received on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (01936) provided on April 16, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the service should be covered. The Plan denied your 
request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia was not filed until February 21, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the anesthesia (01936) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37195 billed for April 6, 2023. 
 
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 payable as billed. 
 
The Plan must follow Medicare rules. The rules say that payment may not be made by carriers for codes with a 
PC/TC indicator of 5 when they are provided to hospital inpatients or patients in a hospital outpatient 
department 
 
We looked at the file and Medicare rules. The file shows that code 37195 has a PC/TC indicator of 5 and was 
billed in the emergency room (hospital outpatient) setting. 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 procedure code 37195 billed for April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 13, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that this claim was submitted correctly. You say 
that this should be reprocessed and paid. The Plan denied your request. The Plan says the claim was not 
received within 12 months from the date of service in this case. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient service was not filed until April 5, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GTI nail wound polymerase chain reaction (PCR) test 
provided on June 21, 2023, and billed with codes 87481, 87500, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the GTI nail wound PCR test. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the GTI nail wound PCR test have not been 
met. Therefore, we decided that the Plan does not have to pay for the GTI nail wound polymerase chain reaction (PCR) test provided on June 21, 2023, and billed with codes 87481, 87500, 87641, 87651, 87653, and 
87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 21, 2023, billed with 
codes 87640, 87581, 87486, 87498, 87541, 87502, 87634 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 21, 2023, billed with codes 87640, 87581, 87486, 87498, 87541, 87502, 87634 and 
87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a specialist office visit. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 specialist office visit to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Citalopram. 
 
You asked the Plan to pre-approve Citalopram. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 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 pre-approve Citalopram.  Benefits for Citalopram 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 7, 2022, to 
July 7, 2022.  
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider is not a Medicare-qualified mental health care professional.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
January 7, 2022, to July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a temporomandibular joint disease (TMJ) office visit 
provided on May 12, 2023. 
 
You asked the Plan to pay for a TMJ office visit. You say that this is not dental, the pain is in your jaw. The 
Plan denied your request. The Plan says TMJ related services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
temporomandibular joint disease (TMJ) office visit provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJI. 
 
You asked the Plan to pre-approve a SIJI. You say that the enrollee's condition requires the requested injection. 
The Plan denied your request. The Plan says the enrollee does not meet the medically necessity criteria for the 
requested joint injection to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a SIJI. 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 documentation of at least three positive findings with provocative maneuvers: 
FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and/or Yeoman Tests. The 
review has determined that the enrollee does not meet the LCD criteria for coverage. 
 
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 SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a SIJI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for May 26, 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 procedure code G0482 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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation 
that the services were performed by the billing provider. 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 procedure code G0482 billed for May 26, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice care rendered on June 1, 2023, to June 30, 2023. 
 
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 Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospice care rendered on June 1, 2023, to June 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and necessary  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction device (E0849) provided on June 13, 
2023. 
 
You asked the Plan to pay for the device. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says this 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 pay for the device. 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 in this case do not document the patient has a musculoskeletal or neurologic 
impairment requiring traction equipment and the appropriate use of a home cervical traction device has been 
demonstrated to the patient and the patient tolerated the selected device and the patient either has a diagnosis of 
temporomandibular joint (TMJ) dysfunction; and has received treatment for the TMJ condition; or, has 
distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be 
utilized; or, the treating practitioner orders and/or documents the medical necessity for greater than 20 pounds 
of cervical traction in the home setting, as required by the guidelines. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pay for a cervical traction device (E0849) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 20, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 20, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF 
admission.  
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee would benefit from the observation and evaluation of a physician given 
his medical history of atrial fibrillation, hypothyroidism, hypertension, and recent meningioma resection with 
resultant right sided hemiparesis. He has had a neurological change and decline in his level of function and 
mobility. He continues to require monitoring by skilled nursing for wound care and medication oversight. He is 
making progress with therapy and would benefit from continued skilled physical and occupational therapies to 
maximize independence with mobility and performing daily activities. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.