Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75625 and 75710. We decided that the Plan does not have to pay for 
75736.  
 
You asked the Plan to pay for aortography and angiography (procedure codes 75625, 75710, 75736) rendered 
on February 11, 2022.. You say that this should be paid for. The Plan says that these denied codes are not 
supported in the medical records submitted. 
 
We decided that the Plan has to pay for 75625 and 75710.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the denied codes is: 
 
 
 CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 for CPT 75625 and CPT 75736. Our reviewer says that 
in terms of CPT 75625 codes for supervision and interpretation of an aortogram. The documentation supports 
this code as the aorta and its iliac branches are described. In terms of CPT 75710, this codes for supervision 
and Interpretation of an extremity angiogram. There is satisfactory documentation of the findings of a pre-
intervention lower extremity angiogram with sufficient detail to justify use of this code. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
75625 and 75710.  
 
We also decided that the Plan does not have to pay for 75736. 
 
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 75736 is "Angiography, pelvic, selective or supraselective, radiological supervision and interpretation." 
 
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 for CPT 75736. Our reviewer says that this codes for 
pelvic angiography required more detailed study of the pelvic vasculature. The documentation does not support 
that this service was provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75736 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75736. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and the 
periodontal scaling and root planing (D4341) provided on October 10, 2022, and November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures should be covered 
because of your medical condition as you need specialist services. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because the comprehensive periodontal evaluation and the 
periodontal scaling and root planing 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) and the periodontal scaling and root planing (D4341) provided 
on October 10, 2022, and November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a lightweight power wheelchair (K0012) 
and accessories provided on March 12, 2022, and March 16, 2022. 
 
You asked the Plan to provide reimbursement for a lightweight power wheelchair and accessories. You say that 
you were never informed of these requirements. The Plan denied your request. The Plan says that lump-sum 
purchases are not permitted. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. A lump-sum purchase is not permitted.  
 
Reimbursement for the power wheelchair cannot be provided through a lump-sum purchase. Therefore, we 
decided that the Plan does not have to provide reimbursement for a lightweight power wheelchair (K0012) and 
accessories provided on March 12, 2022, and March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lubiprostone capsule. 
 
You asked the Plan to pre-approve Lubiprostone. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Lubiprostone capsule.  
 Benefits for Lubiprostone 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), diagnostic radiology procedures of the head and neck (CPT 70310), a swallowing function x-ray 
(CPT 74230), and upper gastrointestinal tract x-ray (CPT 74240) provided on September 8, 2022. 
 You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic 
radiology procedures of the head and neck (CPT 70310), a swallowing function x-ray (CPT 74230), and upper 
gastrointestinal tract x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services do not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of  a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of 
the head and neck (CPT 70310), a swallowing function x-ray (CPT 74230), and upper gastrointestinal tract 
x-ray (CPT 74240) have not been met. Therefore, we decided that the Plan does not have to pay for a 
neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of the head and 
neck (CPT 70310), a swallowing function x-ray (CPT 74230), and upper gastrointestinal tract x-ray 
(CPT 74240) provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on June 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483, 80307) provided on June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cyclosporine ophthalmic emulsion. 
 
You asked the Plan to pre-approve Cyclosporine emulsion. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Cyclosporine ophthalmic emulsion.  
 Benefits for Cyclosporine emulsion 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 7, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 
81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 7, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81403, 81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on March 11, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the medical records support the billing of 
code 99222 provided on March 11, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99222 provided on March 11, 2022. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99222. The definition of CPT code 99222 is Initial hospital care, per day, for 
the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says 
that the medical records do not support the billing of code 99222 provided on March 11, 2022. Our reviewer 
found provided records in this case do not document a comprehensive history. A comprehensive history 
requires 4+ elements in the history of present illness, the provided records document 3 elements. A 
comprehensive history requires 10+ review of organ systems or body areas, the provided records document 6 
organ systems or body areas. Provided records in this case document a comprehensive examination (8+ organ 
systems). Provided records in this case document an acute illness, personal interpretation of a computed 
tomography scan, treatment with a nasogastric tube and intravenous medication (heparin); moderate 
complexity is documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 provided on March 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for code 99213 billed for date of service May 19, 2022. 
 
You asked the Plan to pay for code 99213. You say that the provider did not bill another service on this date of 
service, so there is no bundling issue. The Plan denied your request. The Plan says that this charge is incidental 
to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's only denial rationale is that "this charge is incidental to 
another service."  However, the Plan has failed to provide any documentation of what this 'other service' is.  
There are no other claims or billing information in the limited case file that the Plan submitted to us.  Without 
evidence that other services were billed, a denial based on 'incidental' logic cannot be supported.  The burden is 
on the Plan to show why its denial is appropriate, and the Plan has failed to do so in this case. Therefore, we 
decided that the Plan has to pay for code 99213 billed for date of service May 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet InterQual 2022, Dec. 2022 Release/Medicare: Procedures/Epidural Injections guidelines. 
 
The Plan follows Medicare rules.  
 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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, the most recent ESI on October 5, 2022, provided 100 percent pain relief for six weeks. The review 
has determined that the requested repeat epidural steroid injection did not meet the Medicare LCD coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Minuteman device (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Minuteman device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large-volume, long-term, peer-reviewed outcome studies to support the use of this device for the enrollees 
medical 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 a Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a Minuteman device (22840, 22612).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code 81479 provided on November 24, 2021. 
 
You asked the Plan to pay for code 81479. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that lab code 81479 is not covered. 
 
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. Review of the file shows that the Plan has denied this code due to this code not 
being covered per the 2021 Medicare Lab Fee Schedule. While this code is not listed on the 2021 Medicare 
Lab Fee Schedule, this document does not state that any code not listed is not covered. No other denial 
rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to 
pay for code 81479 provided on November 24, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided by an out-of-network 
provider on September 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was medically necessary, 
and you had to use an out-of-network provider for the services. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because surgical extractions 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical 
extraction (D7210) provided by an out-of-network provider on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted special services, procedures or reports 
(99199) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the unlisted services. You say that you are appealing the denial of monthly 
office visits with this provider. The Plan denied your request. The Plan says enrollee's must receive their 
medical care from an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan also made multiple attempts to 
obtain records and notes from the providers office to approve continuity of care without success. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve the unlisted special services, procedures or reports (99199) to be provided by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be liable because the explanation of benefit (EOB) states you have a zero balance. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69210 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 69210. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 69210 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 69210 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69210 billed for date of service July 19, 2022.