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

 
We decided that the Plan does not have to pay for an interlaminar epidural injection (62323) provided on 
March 30, 2023. 
 
You asked the Plan to pay for an interlaminar epidural injection. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that n Excludes1 is used when two conditions cannot 
occur together, such as a congenital form versus an acquired form of the same condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an interlaminar epidural injection have not been met. Specifically, you have billed the services at issue with ICD-10-CM codes M51.16 and M54.16. Codes within the range M54.1 are subject to an Excludes1 
note that excludes code range M51.1-. Therefore, we decided that the Plan does not have to pay for an 
interlaminar epidural injection (62323) provided on March 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 18, 2022, to 
October 17, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not aware that the Plan was 
going to require a NOA.  Once you learned that it was needed, the NOA was submitted. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
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 start of care date is July 20, 2022. The NOA was not received by the Plan until April 5, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, 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 
September 18, 2022, to October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 20, 2022, to July 
22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care provided from July 
20, 2022, to July 22, 2022, was medically necessary. The Plan denied your request. The Plan says that an 
inpatient admission was 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found per the reviewed documentation, the 74-year-old female patient was directly admitted to the 
hospital on July 20, 2022, from the podiatry clinic with an infection of the right great toe. The podiatrist had 
performed an incision and drainage (l&D). Magnetic resonance imaging (MRI) was ordered due to concern 
regarding possible osteomyelitis. She was treated with intravenous (IV) antibiotics. The MRI showed no 
drainable abscess or significant findings consistent with osteomyelitis. The podiatry consultation on July 21st at 
16:39 noted "cellulitis almost completely resolved. Wound almost healed." She was discharged home on July 
22, 2022, on oral antibiotics. The record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 20, 2022, to July 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided on July 27, 2022. 
 
You asked the Plan to pay for critical care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documents received on appeal consists of duplicates of medical 
documents previously reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of critical care services have been met. 
Therefore, we decided that the Plan does not have to pay for critical care services provided on July 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for alcohol and drug abuse treatment services 
provided from March 3, 2022, to April 19, 2022. 
 
You asked the Plan to reimburse you for alcohol and drug abuse treatment services. You say that the services 
were medically necessary and should be covered as the services were for behavioral health medical alcohol 
problem. The Plan denied your request. The Plan says this provider is a non-participating provider with 
Medicare without a referral or authorization on file. 
 
The Plan must follow Medicare rules. Medicare rules say that a Drug and Alcohol Rehabilitation Counselor is 
not eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Drug and Alcohol 
Rehabilitation Counselor. Medicare says that a Drug and Alcohol Rehabilitation Counselor is not eligible to 
participate in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
alcohol and drug abuse treatment services provided from March 3, 2022, to April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on April 
17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
 Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 
rendered on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on March 29, 2023. 
 
You asked the Plan to pay for oxygen equipment. You say that you are requesting reconsideration for the 
services provided. 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 oxygen equipment 
provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521 rendered on April 3, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
 Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521 rendered 
on April 3, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95927. We decided that the Plan does not have to pay for 95908.  
 
You asked the Plan to pay for procedure codes 95908 and 95927 rendered on September 20, 2021. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 95927.   
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 CPT 95927 is "Short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the 
trunk or head." 
 
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 for CPT 95927. Our reviewer says that the 9/20/21 
technical report cites upper somatosensory evoked potentials (SSEP) stimulation site was the ulnar nerve and 
the lower SSEP stimulation site was the posterior tibial. Therefore, the records support that CPT 95927 was 
rendered in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
95927.  
 
We also decided that the Plan does not have to pay for 95908. 
 
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 CPT 95908 is "Nerve conduction studies; 3-4 studies." 
 
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 for CPT 95908. Our reviewer says that the 9/20/21 
technical report cites the NCV (nerve conduction velocity) recording sites were Erbs point and popliteal fossa. 
This supports 2 recording sites were utilized for 2 studies. Therefore, the records do not support that CPT 
95908 was rendered in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95908 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95908. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on March 18, 2023. 
 
You asked the Plan to pay for critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code was not billed with a valid diagnosis code. 
 
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 99291 is not supported in the medical record. Specifically, diagnosis codes J81.0 
(Acute pulmonary edema) and J69.0 (Pneumonitis due to inhalation of food and vomit) have an exclude note 
and cannot be billed together. Based on this information, we decided that Medicare rules for coverage of 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical 
care services (99291) provided on March 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that the credentialing information has been updated. 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 the office visit provided 
on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on January 24, 2023. 
 
You asked the Plan to pay for a mental health 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 a mental health visit 
provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4221, A4222, J2260) provided on 
August 19, 2022 to August 24, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that these items were medically necessary. 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 which support medical necessity for the supplies provided 
in this case. No itemized shipping receipt was 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 infusion supplies (A4221, A4222, J2260) provided on August 19, 2022 to August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 02, 2022. 
 
You asked the Plan to pay for the office visit. You say that you have included medical records in your request 
for payment. 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 the office visit provided 
on May 02, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90832) provided on 
December 16, 2022 to January 20, 2023. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim was not billed with a valid primary diagnosis 
code. 
 
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 90832 is not supported in the medical record. Specifically, F06.31 is a secondary only 
diagnosis and cannot be billed as a primary diagnosis code. Based on this information, we decided that 
Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for outpatient mental health services (90832) provided on December 16, 
2022 to January 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasound and each specialist office 
visit provided from July 8, 2022, to August 11, 2022. 
 
You asked the Plan to waive the copayments for the ultrasound and each specialist office visit. You say that the 
test was required to be done again. 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 $50 
copayment for diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay a $20 copayment for each specialist office visit. 
 
You have been asked to pay a $50 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have also been asked to pay a $20 copayment 
for each specialist office visit. This item/service falls within the physician/practitioner services 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 copayments for the ultrasound and each specialist office visit 
provided from July 8, 2022, to August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on February 09, 
2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary and 
should be covered. 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 pneumatic 
compression device provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on February 24, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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. The total allowed amount for the prescription drugs is $1,064.85. You are 
being asked to pay $212.97 ($1,064.85 x 20% = $1,064.85). Therefore, we decided that the Plan does not have 
to waive the coinsurance for Medicare Part B prescription drugs provided on February 24, 2023.