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

 
We decided that the Plan does not have to pay for facet joint injection at the additional levels. 
 
You asked the Plan to pay for the injection. You say that it was suggested that the complete medical records be 
submitted, and the claim would be processed accordingly when the Plan reviews the records. The Plan denied 
your request. The Plan says the facet joint injection at the additional levels are 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 pay for the injections. Our reviewer says that the 
enrollee did not meet the LCD coverage criteria. Our physician reviewer found that the enrollee had four levels 
bilaterally. However, only 2 levels bilaterally are allowed per session and there are no extraordinary 
circumstances documented. Therefore, only 2 levels are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pay for facet joint injection at the additional levels.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 rendered 
on March 13, 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 these codes are not appropriate for 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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 
 
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump 
 
Healthcare Common Procedure Coding System (HCPCS) J1817: 
 
Insulin for administration through dme (i.e., insulin pump) per 50 units 
 
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 procedure report describes 
intravenous Novolin R with saline treatment on an outpatient basis. In this a more specific code than CPT 
96365, 96366, and J1817 should be reported. Additionally, the medical records include a physician order for 
refilling and maintenance of the portable pump  CPT 96521. However, this procedure is not included in the 
rest of the documentation submitted, and cannot be verified. 
 
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 96365, 96366, 96521, and J1817 rendered on March 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative electromyography (EMG) billed with code 
51785 for April 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that EMG is covered when specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records do not support that the criteria 
for coverage of EMG are met. The use of intraoperative anal/urethral EMG is not generally accepted as 
reasonable and medically necessary for a thoracic laminectomy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the intraoperative electromyography (EMG) billed with code 51785 for April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus Gene Panel test (81455) provided February 17, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says there is no clinical documentation that the enrollee's cancer is recurrent, relapsed, 
refractory, or advanced and this test is not FDA approved. 
 
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. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer with no 
documentation of advanced cancer. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Tempus 
Gene Panel test (81455) provided February 17, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 00731. We decided that the Plan does not have to pay for 99100.  
 
You asked the Plan to pay for anesthesia services (procedure code 00731 and 99100) rendered on October 7, 
2022.. You say that this should be paid for. The Plan says that the coding is not supported. 
 
We decided that the Plan has to pay for 00731.  
 
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. The provider's National Provider Identifier (NPI) indicates that they are a 
Certified Registered Nurse Anesthetist (CRNA). There is no rule that prevents this provider type from 
administering anesthesia services. Therefore, we decided that the Plan has to pay for 00731.  
 
We also decided that the Plan does not have to pay for 99100. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 99100. 
 
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 procedure code 95861 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 95861. You say that the monitoring can provide critical 
information to the surgeon. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
provided, correctly coded, and medically necessary. Based on this information, we decided that Medicare rules 
for coverage of procedure code 95861 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 95861 billed for date of service April 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20611 and J7323 rendered on November 9, 
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 documentation states that the injections were administered to the right and left lateral 
femorotibial intra-articular space of the knee. 
 
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: 
 
Current Procedural Terminology (CPT) 20611: Arthrocentesis, aspiration and/or injection, major joint or bursa 
(eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting  
Healthcare Common Procedure Coding System (HCPCS) J7323: Hyaluronan or derivative, Euflexxa, for intra-
articular injection, per dose 
 
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 the provider reported three units for 
these codes; however, the procedure report documents "Procedure: Injections of right and left lateral 
femorotibial intra-articular space of the knee." In this case, the additional units for these codes cannot be 
verified, as two injections are only supported in the records. 
 
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 20611 and J7323 rendered on November 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 18, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. 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 psychotherapy provided 
on July 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 81518) rendered on March 23, 
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 that the submitted documentation does not clearly identify the genes tested. 
 
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 81518 is "Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 
content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as 
percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy." 
 
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 supported by the medical records. Our reviewer found that the Breast Cancer Index test is a 
known test which includes a set 11 genes, as outlined in the description and coverage for CPT 81518. The 
records support this coding. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 81518) rendered on March 23, 2023.  
 
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 procedure code 99100 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation services billed with code G0378 for date of service January 1, 2023.

You asked the Plan to pay for observation services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for observation services reported with HCPCS code G0378.

We looked at the file and Medicare rules. Review of the file shows that the code at issue is specifically not separately payable. Based on this information, we decided that Medicare rules for coverage of observation services have not been met. Therefore, we decided that the Plan does not have to pay for observation services billed with code G0378 for date of service January 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic foot (L5647, L8400, L8470). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan, as there is no 
documentation that the enrollee has progressed to being a K3 ambulator. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items including  L5647 addition to lower extremity below knee suction socket; L8400 (prosthetic sheath, socks, shrinkers), and L8470 prosthetic sock single ply fitting below knee are not medically 
necessary. The patient was approved for a K2 new prosthesis in April 2022 and the enrollee's functional 
activities and physician documentation do not support that he has progressed to a K3 ambulator. The 
documentation does not support a need for a K3 foot for the right side. The documentation does not reveal 
objective evidence of a significant change in weight or limb size that indicates that the requested additional 
items are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic foot (L5647, L8400, L8470).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for $250 provided on March 23, 2023. 
 
You asked the Plan to waive the copayment for $250. You say that you were unable to drive yourself. 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 $250 
copayment for in-network ambulance services. 
 
You have been asked to pay a $250 copayment for $250. This item/service falls within the in-network 
ambulance 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 copayment for $250 provided on 
March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 16, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 16, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from August 
16, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 16, 2023, forward. Our physician 
reviewer found as of the last covered day, there is no indication in the available medical records that the 
enrollees psychiatric symptoms could not be managed on a less restrictive basis. As of the last covered day the 
enrollee did not express any active suicidal ideation or intent, or any intent to harm themselves or anyone 
else. The enrollee was not exhibiting any other significant symptoms that would require continued inpatient 
hospitalization. The enrollee had no acute psychiatric issues that would require continued inpatient care beyond 
August 16, 2023. The enrollee has been compliant with medications and has noted improved symptoms. The 
available medical records do not support that continued inpatient care will change these symptoms or the 
enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from August 16, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 16, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 1, 2022, billed with 
evaluation and management (EM) code 99213-25. 
 
You asked the Plan to pay for practitioner services provided. You say that the claim is billed correctly and 
should be paid The Plan denied your request. The Plan says this service is included in the global charge.  
The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 practitioner services provided. Our reviewer 
says that documentation does not support the billed code. Our physician reviewer found that the procedure was 
reported with modifier 25 to bypass National Correct Coding Initiative (NCCI) Edit with an arthrocentesis, 
injection, and/or injection and trigger point injections. After review of the evaluation and management service 
provided during global period, the procedure and modifier is not supported, as documentation does not support 
a significant, separately identifiable service. Evaluation and management relates to the procedures provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of practitioner services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on March 1, 2022, billed with evaluation and 
management (EM) code 99213-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on July 27, 2022. 
 
You asked the Plan to pay for the physical therapy. You say that you are requesting reconsideration for 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 the physical therapy 
provided on July 27, 2022.