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

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and chronic care 
management services provided on April 30, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and chronic care management services. You say 
that the enrollee was in a nursing home setting at the time services were rendered. 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 subsequent nursing 
facility care, and chronic care management services provided on April 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the items/services provided from January 3, 
2023, to May 9, 2023. 
 
You asked the Plan to reduce the cost share for the items/services. You say that you were asked to pay more 
than your out-of-pocket maximum. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $130 
copayment for outpatient advanced imaging services. Your contract with the Plan also clearly says that you 
must pay a $15 copayment for each specialist office visit. Your contract with the Plan also clearly says that you 
must pay a $175 copayment for each outpatient surgery provided at an outpatient hospital. Your contract with 
the Plan also clearly says that you must pay 20% coinsurance for Medicare part B drugs. Your contract with the 
Plan also clearly says that you must pay a $100 copayment for outpatient diagnostic tests provided at an 
outpatient hospital.  
 
Date of Service CPT Code Allowed Amount Copayment Coinsurance 
January 3, 2023 71260 $161.07 $130 - 
January 5, 2023 99214 $122.51 $15 - 
January 12, 2023 99215 $176.06 $15 - 
January 12, 2023 J9394 $156.90 - $31.38 
January 12, 2023 96365 $84.60 - $16.92 
January 16, 2023 50590 $3,281.47 $175 - 
January 17, 2023 99213 $94.04 $15 - 
January 20, 2023 99213 $82.23 $15 - 
February 10, 2023 99215 $176.06 $15 - 
February 13, 2023 68761 $150.60 $15 - 
February 13, 2023 96365 $84.60 - $16.92 
February 13, 2023 J9394 $156.90 - $31.38 
February 14, 2023 99213 $94.04 $15 - 
March 7, 2023 74177 $444.50 $130 - 
March 8, 2023 99215 $176.06 $15 - 
March 9, 2023 99441 $58.19 $15 - 
March 10, 2023 99205 $216.02 $15 - 
March 10, 2023 93005 $58.85 $58.85 - 
March 13, 2023 J0897 $2,768.04 - $553.61 
March 13, 2023 J9394 $156.90 - $31.38 
March 17, 2023 99214 $119.30 $15 - 
March 23, 2023 31652 $3,413.06 $175 - 
March 30, 2023 99212 $55.48 $15 - 
April 5, 2023 99215 $176.06 $15 - 
April 7, 2023 99214 $119.30 $15 - 
April 10, 2023 J0897 $2,762.16 - $552.43 
April 10, 2023 96372 $27.63 $27.63 - 
April 13, 2023 36561 $3,049.93 $175 - 
April 20, 2023 99213 $84.28 $15 - 
May 5, 2023 38222 $2,644.78 $175 - 
May 9, 2023 96367 $27.63 - $5.53 
May 9, 2023 96413 $136.22 - $27.24 May 9, 2023 J0897 $2,762.16 - $261.73 
Total $2,800 
 
The record shows your out-of-pocket maximum was processed correctly. 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 reduce 
the cost share for the items/services provided from January 3, 2023, to May 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service March 24, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 was not supported by the medical record because the 
clinical information does not show high medical decision making or high severity/immediate significant threat 
to life or physiological function. As a result, this service was down-coded to code 99284. 
 
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, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity.  
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the enrollee is a 96-year-old female with diabetes mellitus 
type 2, dementia, and hypertension. She presented to the emergency room with bilateral lower extremity 
numbness, but not weakness beyond her usual baseline. The treating physician noted that, "at their worst the 
symptoms were mild in the emergency department the symptoms are unchanged or improved..." The higher 
billing code is not applicable because the presenting problem was not high risk, nor was it immediately a threat 
to life or physiological function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on May 03, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 23, 2023, billed 
with codes 95886, 95908, and 95937. 
 
You asked the Plan to pay for the services as billed. You say that the services are supported and should be paid. 
The Plan denied your request. The Plan says the codes are 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 95908 is nerve conduction studies; 3-4 studies.  
 
The definition of 95886 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 
 
The definition of 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, 
any 1 method. 
 
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 as billed. Our reviewer says that the billed 
services are not supported.  Our reviewer found in regard to code 95908, the procedure note describes pedicle 
screw stimulation, which would not be reported with this procedure code as nerve conductions studies assess 
amplitude, latency, and configuration of nerve conduction velocities. Code 95886 is an add-on code for 95908 
and is not supported because 95908 is not supported. For 95937, the documentation shows that train-of-four 
testing was performed. This is not the appropriate code to report this service. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on February 23, 2023, billed with codes 95886, 95908, 
and 95937.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 80048, 83036 and 85025 
provided September 24, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the enrollee did not provide the insurance 
information at the time of service. The Plan denied your request. The Plan says the time limit for filing has 
expired. 
 
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 laboratory service was not filed until May 3, 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 laboratory service coded as 80048, 83036 and 85025 provided September 
24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajovy. 
 
You asked the Plan to pre-approve the medication. You say that Ajovy is medically necessary. 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 Ajovy.   
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve the medication. 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 Xarelto.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and related services provided on 
May 03, 2023. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that this enrollee does not 
need a referral to see this provider. 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 new patient office 
visit, and related services provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TPI. 
 
You asked the Plan to pre-approve the TPI. You say that the enrollee had tenderness to palpation around the 
spine which we would be treating with TPI. The Plan denied your request. The Plan says the criteria for 
coverage 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 the TPI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of a taut band that is palpable or documentation of restricted 
range of motion. There is no documentation that the underlying cause of a trigger point is being addressed. 
There is no documentation that non-injection therapies have been tried. Therefore, the criteria for coverage 
have not been 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 the TPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TPI.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 29, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you believe this claim should be paid. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 18, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided on November 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 23, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient was seen in a hospital setting. The 
Plan denied your request. The Plan says you billed this claim with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on November 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 7, 2023, to 
February 5, 2023. 
 You asked the Plan to pay for the home health services. You say that you submitted your NOA to the 
intermediary and there is no requirement that this be sent to the Plan. The Plan denied your request. The Plan 
says the NOA was not received. As such, this final claim was correctly denied. The Plan says that although you 
contend that the NOA was submitted, none has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 7, 
2023, to February 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the commode chair. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid proof of delivery.  There is no shipping or delivery information at all 
provided. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the commode chair billed for date of 
service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI injection. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for coverage 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 the ESI injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of lumbar radiculopathy, radicular pain and/or 
neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc 
disease, producing foraminal or central spinal stenosis, or post-laminectomy syndrome. Therefore, the criteria 
for coverage have not been 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 the ESI injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an ESI.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve block (64488) provided on February 21, 2023. 
 
You asked the Plan to pay for the nerve block. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed 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 64488 is a Transversus abdominis plane (TAP) block. 
 
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 nerve block. Our reviewer says that the records do not 
support the code billed. Our reviewer found the records do not support that this service was separate from the 
anesthesia services billed (code 00790). Use of the 59 modifier is not supported.  
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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pay for a nerve block (64488) provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 7, 2023, billed with 
code 99236. 
 
You asked the Plan to pay for the services as billed. You say that the code billed is supported.  The Plan denied 
your request. The Plan says this code 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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 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 as billed. Our reviewer says that the code at 
issue is not supported.  Our reviewer found the patient is a 70-year-old female who was treated in the hospital. 
The documentation from this date describes the patient with sudden abdominal pain. The history was 
comprehensive. Workup suggested choledocholithiasis. She was treated with morphine. Vitals were stable. 
Physical examination was an expanded focus, not comprehensive. The plan included continued pain 
management, imaging, and observation status. The records do not support that the medical decision making 
was of high complexity as the patient was stable and only required observation status.  
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on March 7, 2023, billed with code 99236.