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

 
We decided that the Plan does not have to pay for a home or residence visit provided on September 15, 2023. 
 
You asked the Plan to pay for a home or residence 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 home or residence visit provided on September 15, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for date of service July 6, 2023. 
 
You asked the Plan to pay for procedure code H2019. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2019 billed for date of service July 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
April 12, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the claim was not filed in a timely manner. 
 
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 subsequent nursing facility care services was not filed until July 18, 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 subsequent nursing facility care services 
provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6196 and A6212 provided on October 25, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes A6196 and A6212. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
procedure codes A6196 and A6212 provided on October 25, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prothrombin time provided on September 18, 2023. 
 
You asked the Plan to pay for prothrombin time. You say that this service was 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 prothrombin time provided on September 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 19, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on September 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 27, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 99140. The Plan denied your request. The Plan says procedure 
code 99140 is considered bundled and 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 procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. 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 procedure code 
99140 billed for date of service September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous Basivertebral nerve, 
including all imaging guidance; first two vertebral bodies (64628) and each additional vertebral body (64629). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous Basivertebral nerve, including all 
imaging guidance; first two vertebral bodies (64628) and each additional vertebral body (64629). You say that 
the request is not medically necessary. The Plan denied your request. The Plan says you provided medical 
records and would like the procedure to be reconsidered. 
 
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 thermal destruction of intraosseous 
Basivertebral nerve, including all imaging guidance; first two vertebral bodies (64628) and each additional 
vertebral body (64629). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only Modic changes (MC) without facet degenerative joint disease or stenosis. The cause of 
pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous Basivertebral nerve, including all imaging 
guidance; first two vertebral bodies (64628) and each additional vertebral body (64629) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
Basivertebral nerve, including all imaging guidance; first two vertebral bodies (64628) and each additional 
vertebral body (64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the core buildup, including any pins when 
required (D2950) provided on August 14, 2023. 
 
You asked the Plan to issue reimbursement for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this dental item is 
not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided in this case is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the core buildup, including any pins when required (D2950) provided on August 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that you do not have direct patient contact. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are requesting reconsideration 
stating you have tried alternate therapies, and nothing has worked. The Plan denied your request. The Plan says 
a review of the current medical literature shows that the evidence is insufficient to determine that this service is 
standard medical treatment for these indications. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have chronic low back pain and sacroiliitis. You had diagnostic lateral and 
medial sacral nerve blocks. This is considered an experimental/ investigational procedure because of the wide 
variation in efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically 
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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance (64625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that the sprint PNS system will be used to 
assess the enrollee's suitability for a permanent PNS implant. The Plan denied your request. The Plan says the 
sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is considered the subject of ongoing clinical trials and is considered experimental and investigational. 
 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
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 this is medically necessary. 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 enrollee is noted to have an 
established diagnosis of Lewy Body Dementia. The enrollee was not noted in the records to be suspected of 
having either let alone both AD and FTD. Nor did he meet diagnostic criteria for both AD and FTD. 
 
   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 17, 2023, billed 
with procedure codes 76942-26 and 20553-XS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
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 October 23, 2023. 
 
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 practitioner services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on August 17, 2023, billed with procedure codes 76942-
26 and 20553-XS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on September 14, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the lab testing. You say that the test is exclusively available through the provider. 
The Plan denied your request. The Plan says utilization of network providers and authorization for certain 
services is required. 
 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 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 OON services. Therefore, we decided 
that the Plan does not have to pay for the lab testing provided on September 14, 2023, by an out-of-network 
(OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93926 billed for date of service July 28, 
2023. 
 
You asked the Plan to pay for the billed service. You say that you are billing for the interpretation of the 
radiological service. The Plan denied your request. The Plan says the billed service is not supported. 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. Code 93296, a duplex scan of the lower extremity, is not supported. 
There are no medical records provided to show that the services were provided, correctly coded, and medically 
necessary. The file does show that the Plan made multiple attempts to obtain additional information with no 
success. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93926 billed for date of service 
July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2332) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service. 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 August 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a filling (D2332) provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services described by code 99153 
performed on July 26, 2023.  

You asked the Plan to pay for 99153. You say that 99153 should be paid as billed because it is supported in the 
medical record. The Plan denied your request. The Plan says 99153 is denied because this code is not payable 
in the facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
PE only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file and Medicare rules. In this case, we confirmed that the claim was billed with place of 
service 21, indicating the services were rendered in the inpatient hospital setting. We find that payment for CPT 
code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 
when performed in the facility setting. Based on this information, we decided that Medicare rules for coverage 
of 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services described by code 99153 performed on July 26, 2023.