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

 
We decided that the Plan does not have to pre-approve genicular nerve block (64624). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 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 nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block (64624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 18, 2022 to 
December 31, 2022. 
 You asked the Plan to pay for the home health services. You say that your billing software had issues that 
prevented the filing of this NOA. 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 August 20, 2022. The NOA was not received by the Plan until March 9, 
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 December 18, 2022 to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 for date of service December 15, 
2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows 
that only 21 drug classes were identified. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0483 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0483 for date of service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for the billed services. You say that previous claims were paid with the diagnosis 
codes. The Plan denied your request. The Plan says the diagnosis code pair should not be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 The claim shows that CPT code 97164 was billed with diagnosis codes R26.2 and R26.81. We find that 
diagnosis code R26.2 has an Excludes1 note indicating diagnosis code R26.81 should never be used at the same 
time. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 97164 billed for date of 
service December 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99219) provided on January 10, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99219 is Initial observation care, per day, for the 
evaluation and management of a patient. 
 
We find that CPT code 99219 is not supported in the medical record. Specifically, per Local Coverage Article: 
Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985) the code 
billed was not a valid code for this service on the date of service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99219) provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87653, 87801, 87481, 87798) provided on 
December 9, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. There 
were network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services (87653, 87801, 87481, 87798) 
provided on December 9, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) billed for 
date of service December 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical literature shows the efficacy of the 
treatment rendered. The Plan denied your request. The Plan says the device is not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The billed heating pad has not been established as reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) 
billed for date of service December 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on December 
26, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services are supported in the medical 
record and should be paid. The Plan denied your request. The Plan says the payment for these services is 
included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility from December 22, 2022, to December 28, 2022. This means that the services at 
issue are considered patient transportation and paid to the facility. Therefore, we decided that the Plan does not 
have to pay for ambulance services (A0429, A0425) provided on December 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has experienced memory loss and 
cognitive difficulty performing everyday tasks. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided do not readily 
demonstrate that the member meets diagnostic criteria for AD or FTD. There is no indication that the member 
satisfies the diagnostic criteria for both conditions. As the primary requirement of the NCD has not been 
satisfied, this service would not be eligible 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Auvelity. 
 
You asked the Plan to pre-approve Auvelity. You say that the enrollee would like reconsideration based on the 
records submitted The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 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 Auvelity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lidocaine pad. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 lidocaine pad.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on January 13, 2023. 
 
You asked the Plan to pay for initial hospital care. 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have not been met. Specifically, the services at issue have been reported with 
diagnosis codes R78.81 and F19.10. Code R78.81 is marked with an Excludes1 note, indicating it cannot be used at the same time as an F19 code. Therefore, we decided that the Plan does not have to pay for initial 
hospital care (99223) provided on January 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291) provided on August 28, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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, this code is included in the 
global surgery package of code 32551 which was billed for the same date of service. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services (99291) provided on August 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73030 and 73080 billed for date of service 
December 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are covered by the fee schedule. The 
Plan denied your request. The Plan says the codes are not separately payable. 
 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 codes 73030 and 73080 have a Q1 status indicator. The codes were billed on the same day as 
code 99284, which has a status indicator of V. This means that the codes at issue are not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 73030 and 73080 billed for 
date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided by an out-of-network (OON) 
provider on December 20, 2022. 
 
You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that out-of-network 
outpatient diagnostic tests require prior authorization. 
 
 
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of OON laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided by an out-of-network (OON) 
provider on December 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 a sleep study. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the review indicates that the 
documentation indicates that the enrollee has good control of established sleep apnea diagnosis with use of 
continuous positive airway pressure (CPAP) since 2007. There are no changes in their condition which would 
warrant a new sleep study prior to obtaining a new CPAP machine. The review has determined that the enrollee 
does not meet the coverage criteria detailed in the LCD.  
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on February 8, 2023, by an out-of-
network (OON) provider at the in-network rate.  
 
You asked the Plan to pay for OON x-ray services at the in-network rate. You say that the enrollee could not 
choose an in-network provider. The Plan denied your request. The Plan says this processed correctly. 
 
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 at the in-network rate only in cases 
involving emergencies, out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for x-ray services provided on February 8, 2023, by 
an out-of-network (OON) provider at the in-network rate.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 16, 2022, to 
October 13, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the claim is correct. 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 September 16, 2022. The NOA was not received by the Plan until 
November 18, 2022. 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 16, 2022, to October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 11, 
2022. 
 You asked the Plan to pay for the billed services. You say that the previous claim was paid. The Plan denied 
your request. The Plan says an appropriate primary diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim shows that CPT code 99232 was billed with primary diagnosis code F06.30. Diagnosis code F06 has 
a code first notation indicating it is not permitted to be used as the primary diagnosis. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 11, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service September 
26, 2022. 
 You asked the Plan to pay for procedure code 97164. You say that the services were medically appropriate and 
necessary. The Plan denied your request. The Plan says payment for code 97164 is bundled into payment for 
code G0283. 
 
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 97164 is a column II code to column I code G0283. Code 97164 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 97164 
billed for date of service September 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 4, 2021.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the appropriate 
modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services require the use of an appropriate 
modifier.  
 
We looked at the file and Medicare rules. The therapy services in this case were billed without the appropriate 
modifier. This resulted in the denial of the entire claim. 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 the services provided on October 4, 2021.