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

 
We decided that the Plan does not have to pay for procedure codes G0283, J1955, J3411, J3415, J3420 
rendered on October 26, 2022. 
 
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 these medications are included in the nutria-pharmaceutical blend/mix, and cannot be reported 
separately. 
 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) G0283: 
 
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a 
therapy plan of care 
 
HCPCS J1955: 
 
Injection, levocarnitine, per 1 gm 
 
HCPCS J3411: 
 
Injection, thiamine hcl, 100 mg 
 
HCPCS J3415: 
 
Injection, pyridoxine hcl, 100 mg 
 
HCPCS J3420: 
 
Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that at present, the literature and 
scientific evidence supporting the 
use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation 
alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is insufficient to 
warrant coverage. These procedures are considered investigational and are not eligible for coverage for the 
treatment of neuropathies or peripheral  neuropathies caused by underlying systemic diseases. Therefore, it is 
inappropriate to bill G0283 for this service. 
 
The remainder of the denied codes are ineligible for separate reimbursement, as they are included in the nutria-
pharmaceutical blend/mix. Individual drugs included in a compound mix are not separately billable. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes G0283, J1955, J3411, J3415, J3420 rendered on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of injection 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 one to two levels are allowed per session per spine region. 
 
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be 
considered under unique circumstances and with sufficient documentation of medical necessity on appeal 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the third level exceeds utilization criteria of the LCD for the number of levels treated in a session. 
There is no extraordinary reason given to exceed this limitation. Therefore, the third level is deemed not 
medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a third level of injection rendered on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for grief counseling provided from November 15, 2022, to 
January 31, 2023. 
 
You asked the Plan to pay for grief counseling. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider is not eligible to participate in Medicare. Services provided by 
a Licensed Professional Counselor are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional 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 Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for grief counseling provided from 
November 15, 2022, to January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00300) provided on February 3, 
2023. 
 
You asked the Plan to pay for the anesthesia services. You say that you had no other insurance and should not 
be charged for these services. The Plan denied your request. The Plan says your eligibility reveals the Plan was 
secondary payer on the date of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the primary payer will 
need to review the services for payment consideration before the Plan can consider the claim for payment 
consideration as secondary payer. As the secondary insurer, the Plan cannot be held responsible for the 
anesthesia services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the anesthesia services (00300) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
10, 2022. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99223. The documentation available for review does not support the encounter 
contained a comprehensive physical examination. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
April 22, 2023, to April 25, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you were in and out 
of the hospital multiple times this month, and you do not understand where there are so many copayments. 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 $395 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $395 copayment per admission for an in-network inpatient stay.  
This item/service falls within the inpatient hospital care 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 an in-network inpatient stay provided from April 22, 2023, 
to April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J2278 and J3490 rendered on March 9, 
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 denied codes remain not supported, as there is a more appropriate code to use. 
 
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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) J2278: 
 
Injection, ziconotide, 1 microgram 
 HCPCS J3490: 
 
Unclassified drugs 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support the codes as there are more appropriate codes that can be used to specify the infusion performed on 
the enrollee. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes J2278 and J3490 rendered on March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty to L2, L3, and L4. 
 
You asked the Plan to pre-approve the kyphoplasty to L2, L3, and L4. You say that the enrollee is in horrible 
pain and needs some kind of relief. The Plan denied your request. The Plan says  the kyphoplasty 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 pre-approve the kyphoplasty to L2, L3, and L4. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for age-related osteoporosis with current pathological 
fractures. The detailed documentation does not how acute/subacute vertebral fractures at all of the requested 
surgical levels. The vertebral height loss is not corroborated on MRI at all of the requested levels. There is no 
indication of a progression of the body height loss, greater than 25% vertebral body height loss at L2, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is MRI corroboration of other plausible 
causes of pain. Therefore, the requested kyphoplasty at L2, L3, and L4 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 kyphoplasty to L2, L3, and L4 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the kyphoplasty to L2, L3, and L4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary for the patient's condition. The Plan denied your request. The Plan says the clinical value 
and effectiveness of a genicular artery embolization in the setting of knee osteoarthritis have not been 
demonstrated in the peer-reviewed literature. 
 
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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has osteoarthritis of the left knee. The 
enrollee has tried and failed conservative therapy. Genicular artery embolization is considered experimental/ investigational at this time.  Therefore, the request is deemed not medically reasonable and 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D0140, D0220, D0230, D0270, D0364, 
D0460, D3330, D9215). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. 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 April 27, 2023. Therefore, we decided that the Plan does not have to pre-approve dental services (D0140, D0220, D0230, 
D0270, D0364, D0460, D3330, D9215).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine culture testing billed with code 87086 for date of 
service March 13, 2023. 
 
You asked the Plan to pay for the urine culture testing.. You say that this service was medically necessary and 
covered by Medicare. The Plan denied your request. The Plan says you did not bill this service with a covered 
diagnosis code. 
 
The Plan must follow Medicare rules. The rules state that urine culture testing is coverable when billed with a 
covered diagnosis. The covered diagnoses are listed in the Covered Code list.  
 
In this case, the only diagnosis you billed on the claim was N31.8.  Diagnosis code N31.8 is not listed in the 
Covered Code List, so this is not a covered diagnosis for this service. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture testing. have not been met. Therefore, we decided that the Plan does not have to 
pay for urine culture testing billed with code 87086 for date of service March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 10, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral knee braces (L1843) and suspension sleeves 
(L2397) provided on February 22, 2023. 
 
You asked the Plan to pay for the braces with sleeves. You say that the medical record justifies the need for the 
knee braces. The Plan denied your request. The Plan says criteria for the braces are not met.  
 The Plan follows Medicare rules. Medicare rules say that the type of knee brace requested in this case is 
covered for enrollees with recent injury or surgery, or who have documented knee instability.  
 
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 braces with sleeves. Our reviewer says 
that the criteria for the requested knee braces are not met.  Our physician reviewer found the enrollee has 
chronic osteoarthritis of her knees. There is no current physical exam of her knees in the record. There is no 
documented knee instability, recent injury, or surgery which is required for coverage of this type of brace.  
 
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 braces with sleeves have not been met. Therefore, we decided that the Plan 
does not have to pay for bilateral knee braces (L1843) and suspension sleeves (L2397) provided on February 
22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services/other/therapeutic procedure/manual 
therapy techniques/electrical stimulation provided on July 7, 2022. 
 
You asked the Plan to pay for the practitioner services/other/therapeutic procedure/manual therapy 
techniques/electrical stimulation. You say that the services were medically necessary. The Plan denied your 
request. The Plan says the plan did not receive a primary carriers Explanation of Benefits. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the practitioner services/other/therapeutic procedure/manual therapy 
techniques/electrical stimulation until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for practitioner services/other/therapeutic procedure/manual therapy 
techniques/electrical stimulation provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 7, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on March 7, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for needle electromyography guidance for a chemodenervation injection 
provided on December 13, 2022. 
 
You asked the Plan to pay for needle electromyography guidance for a chemodenervation injection. You say 
that the services were medically necessary. The Plan denied your request. The Plan says that the procedure note 
does not indicate that EMG diagnostic testing was used for location of these injections. CMS correct coding 
initiative was used for this determination. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a coding rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for needle electromyography guidance 
for a chemodenervation injection provided on December 13, 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.