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

 
We decided that the Plan does not have to pay for angiography services (procedure codes 75726, 75774) 
provided to the enrollee on February 18, 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 denied codes cannot be verified. 
 
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 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
 
 CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 documentation does not 
provide support for use of the codes in question.  The medical records provided do not appear to contain the 
operative report or description of the procedure. From the records provided, it is documented that liver tumor 
embolization was being planned. 
 
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 angiography services (procedure codes 75726, 75774) provided to the enrollee on February 18, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from 
September 5, 2022, through September 6, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from September 5, 2022, through September 6, 2022.  
 Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 2, 2021 to 
November 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. You say that you went to Alaska where your son could take care of 
you after surgery. The Plan denied your request. The Plan says this physical therapy was not unforeseen or 
urgent. 
 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. These 
services would not be considered urgent, emergent, or unforeseen. Therefore, we decided that the Plan does not 
have to pay for physical therapy services provided on November 2, 2021 to November 24, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (procedure code G0483) provided to the enrollee on June 27, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not show screening test results which are positive or inconsistent with prescription 
medication, dosing schedules, or history and expected results. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the reviewed documentation indicates that the condition of the enrollee did not meet the Medicare 
rules for approval of definitive urine drug testing. The review has determined that the records did not support 
that the enrollee needed 22 or more drug classes tested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (UDT) for 22 or more drug classes (procedure code G0483) provided to 
the enrollee on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a limited budget, and you believe the 
services should be covered. 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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) but each service is limited to on procedure every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation - new or established patient (D0150) and 
intraoral - complete series of radiographic images (D0210) was exhausted on date of service November 18, 
2020. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or 
established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided on July 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on August 1, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on May 6, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on May 6, 2022.  
 Your complaint about waiting 45 minutes for the doctor is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), pulp vitality test (D0460), 
apicoectomy (D3425 and D3426) and retrograde filling (D3430) for tooth #30 provided on July 18, 2022, and 
August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like reconsideration for payment on 
the dental services. The Plan denied your request. The Plan says your benefit for the oral evaluation has already 
been exhausted. The denial of payment for the pulp vitality test, apicoectomy and retrograde filling is correct, 
because they are not covered by the Plan. 
 
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 oral evaluation was exhausted on the date of service of June 29, 2022. The pulp 
vitality test, apicoectomy and retrograde filling are not covered under the Plans dental benefit.  Therefore, we 
decided that the Plan does not have to pay for an oral evaluation (D0140), pulp vitality test (D0460), 
apicoectomy (D3425 and D3426) and retrograde filling (D3430) for tooth #30 provided on July 18, 2022, and 
August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 27507) provided to the 
enrollee on May 14, 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 27507 is "Open treatment of femoral shaft fracture with 
plate/screws, with or without cerclage." 
 
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 records do not support that 
CPT 27507: open treatment of femoral shaft fracture with plate/screws, with or without cerclage was rendered 
in this case. The enrollee was being treated for periprosthetic fracture around internal prosthetic left hip joint. 
He underwent an ORIF (open reduction internal fixation) of the left femur and revision of left hip arthroplasty of the femoral component on 5/4/22. The procedure in detail cites the fracture edges were cleaned of the lateral 
fracture spike as well as additional fractures lines through the femoral shaft. Entrapped soft tissues were 
debrided. The fracture areas were lavaged thoroughly. Once they were cleaned and free of soft tissue, they were 
reduced according to the cortical reads that were present using large pointed reduction forceps. Cerclage cables 
were placed for internal fixation of the femur. 3 cerclage cables were placed in total, fixing the main fracture 
lines. However, there is no indication that plates and screws were utilized in this procedure. 
 
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 surgical services (procedure code 27507) provided to the enrollee on May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95865, 95886, 95908 and 95937 billed for 
date of service June 7, 2022. 
 
You asked the Plan to pay for procedure codes 95865, 95886, 95908 and 95937. You say that these services 
were reported appropriately. The Plan denied your request. The Plan says these services are not supported 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. 
 
 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 procedure codes 95865, 95886, 95908 and 95937. Our 
reviewer says that these services are not supported in the medical records provided. Our reviewer found that the 
procedure report documents, Endotracheal tube was utilized to monitor Recurrent Laryngeal Nerve during the 
procedure. Various, transient activity witnessed during procedure as manipulation of the nerve occurred, 
however, all activity returned to baseline prior to end of procedure. The surgeon was made aware of activity. 
The procedure report does not include sufficient documentation to report code 95865. Codes 95886 and 95908 
also are not supported, as nerve conduction studies are not sufficiently documented and cannot be verified. In 
addition, the procedure report describes train of four (TO4) testing. Neuromuscular junction testing is an 
inappropriate code to report for TO4, TO4 is included in the primary neuromonitoring procedure. Therefore, 
these services are not supported as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95865, 95886, 95908 and 95937 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95865, 95886, 95908 and 95937 billed for 
date of service June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic capsulorrhaphy. 
 
You asked the Plan to pre-approve arthroscopic capsulorrhaphy. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services 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 pre-approve arthroscopic capsulorrhaphy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for unspecified rotator cuff tear or rupture of 
the right shoulder. The enrollee presented with right shoulder pain. The exam reveals tenderness to palpation 
over her long head biceps tendon anteriorly within the bicipital groove. The enrollee also has significant 
tenderness over the anterior acromioclavicular joint area. Neers, Hawkins, and OBriens were positive.  There is significant pain and moderate weakness with resisted supraspinatus testing consistent with recurrent 
rotator cuff tear. However, there is a lack of large-volume, long-term peer-reviewed outcome studies to support 
the use of superior capsular release as a reliably effective treatment. The MRI of the right shoulder does not 
corroborate a massive, irreparable rotator cuff tear. There was no evidence of any extenuating circumstances in 
this enrollees specific case either. Therefore, the enrollee does not have a diagnosis/condition that meets 
criteria for the requested arthroscopic capsulorrhaphy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroscopic capsulorrhaphy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthroscopic capsulorrhaphy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for items and services provided during an inpatient 
hospitalization from July 20, 2021, to August 5, 2021, totaling $18714.58. 
 You asked the Plan to pay for items and services provided during an inpatient hospitalization. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these 
items and services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment for inpatient hospital services 
includes general routine services and special care unit services. Routine services include regular room, dietary 
and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, 
and the use of certain equipment and facilities for which a separate charge is not customarily made. 
 
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 items and services provided during an inpatient 
hospitalization. Our reviewer says that these items and services are not eligible for separate payment. Our 
reviewer found the enrollee received inpatient hospital services on July 20, 2021, through August 5, 2021.  
Provider reported multiple nursing services and supplies separately from "room and board" services.  
Documentation submitted was reviewed and does not meet criteria.  After careful review of the separately 
charged services and medical record, services provided would be inclusive to the daily service charge ("room 
and board") payment. Per CMS, "Included in routine services are the regular room, dietary and nursing 
services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use 
of certain equipment and facilities for which a separate charge is not customarily made". Billed services fall 
into nursing services and minor medical and surgical supplies and therefore would not be covered separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of items and services provided during an inpatient hospitalization have not been 
met. Therefore, we decided that the Plan does not have to pay for items and services provided during an 
inpatient hospitalization from July 20, 2021, to August 5, 2021, totaling $18714.58.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature (L5845). 
 
 
 
 You asked the Plan to pre-approve a prosthetic component. You say that the enrollee is a new bilateral above 
knee amputation. She has never had prostheses. What you have requested authorization for are to be her first 
set of bilateral temporary prostheses. Without these, she cannot begin training in physical therapy to relearn 
how to walk. Without bilateral prostheses, the enrollee cannot return to independently maintaining her home, 
driving, and taking care of herself. The Plan denied your request. The Plan says the requested code cannot be 
used for this prosthetic component and is unbundled. Although the vendor may use the code L5845 for their 
requested knee, neither the manufacturer nor the vendor has the authority to assign this code to the requested 
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. 
 
We find that CPT code L5845 is not supported in the medical record. Specifically, code L5845 cannot be used 
for this specific prosthetic component and is considered unbundled. Based on this information, we decided that 
Medicare rules for coverage of a prosthetic component have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature (L5845).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 95822. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this service is not supported 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 95822 is electroencephalogram (EEG); recording in coma or sleep only. 
 
 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 procedure code 95822. Our reviewer says that this service is 
not supported in the medical records provided. Our reviewer found that code 95822 is an inappropriate code to 
report for EEG during non-intracranial surgery service. CPT 95822 would be reported for a routine test to 
diagnose a seizure disorder, with, if needed further testing to confirm or rule out epilepsy. In this case, CPT 
95822 is not supported by the medical record, and therefore 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 procedure code 95822 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95822 billed for date of service April 13, 2022.