Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device. 
 
You asked the Plan to pre-approve these services. You say that you had right rotator cuff surgery. The Plan 
denied your request. The Plan says the services are not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion (CPM) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96130 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is no 
documentation of a mental health disorder. 
 
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 96130 is psychological testing evaluation services by 
physician or other qualified health care professional, including integration of patient data, interpretation of 
standardized test results and clinical data, clinical decision making, treatment planning and report, and 
interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. 
 
We find that CPT code 96130 is not supported in the medical record. Screening procedures provided routinely 
to patients without regard to the signs and symptoms of the patients mental illness do not represent reasonable 
and necessary outpatient psychiatric services. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 96130 billed for date of service August 19, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 provided on September 9, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99285 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99285 provided on September 9, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (62628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (62628).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantable tissue marker (A4648). 
 
You asked the Plan to pre-approve the services. You say that the enrollee's doctors agree that the enrollee is in 
need of radiation due to prostate cancer. You state the enrollee is supposed to have implants in a week and a 
half. The Plan denied your request. The Plan says that the enrollee's records do not show that this request is 
from a radiation oncologist, in conjunction with the placement of interstitial device(s) for radiation therapy 
guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple (CPT code 
55876). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found CPT codes 55876 and A4648 are medically reasonable and necessary in this case. The radiation 
oncologist would like this done in order to guide the external beam radiation treatment (EBRT) that is planned. 
 
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 pre-
approve implantable tissue marker (A4648).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43653 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed service 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 code 43653 is Laparoscopy, surgical; gastrostomy, without 
construction of gastric tube (e.g., Stamm procedure) (separate procedure). 
 
We find that CPT code 43653 is not supported in the medical record. The medical records indicate that the 
surgery would be performed in an operating room with anesthesia. The records do not show that a surgical 
gastrostomy was performed during the visit at issue. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 43653 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for a new-patient eye exam. We decided that the Plan does not have to pay 
for a determination of refractive state.  
 You asked the Plan to pay for a new-patient eye exam (92004) and a determination of refractive state (92015) 
provided on August 17, 2022. You say that the services at issue were a medical necessity for the enrollee. The 
Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for a new-patient eye exam.  
 
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 for a new-patient eye exam. Specifically, the Plan has denied payment for a new-
patient eye exam because the service at issue was billed with diagnosis code H53.001, Unspecified amblyopia, 
right eye. The Plan states this is a routine condition and not appropriate to be billed for non-routine medical 
services. However, we find that the Plan has not cited any rules that establish code H53.001 as a routine 
condition. The Plan has not provided any alternative rationales for denial. It is the Plans responsibility to 
substantiate its denial with evidence. In this case, the Plans denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pay for a new-patient eye exam.  
 
We also decided that the Plan does not have to pay for a determination of refractive state. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for procedures performed in 
the course of any eye exam to determine the refractive state of the eyes. 
 
Procedure code 92015 indicates a procedure to determine the refractive state of the eyes. Therefore, we decided 
that the Plan does not have to pay for a determination of refractive state. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37211 and 75820 billed for date of service 
August 24, 2022. 
 
You asked the Plan to pay for procedure codes 37211 and 75820. The Plan denied your request. The Plan says 
payment for codes 37211 and 75820 is bundled into payment for code 37187.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
37211 and 75820 are column II codes to column I code 37187. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 37211 and 75820 billed for 
date of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve and additional six radiation therapy field treatments of a single 
treatment area (code 77280). 
 
You asked the Plan to pre-approve radiation therapy field treatments of a single treatment area. You say that 
you do not want to have your nose cut up; the skin does not heal correctly so you want to do the radiation 
treatment. The Plan denied your request. The Plan says that this service is approved for 1 unit only. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 additional six radiation therapy field 
treatments of a single treatment area. Our reviewer says that the requested additional six radiation therapy field 
treatments of a single treatment area are considered medically reasonable and necessary in this case. Our 
physician reviewer found based on community standard of care, the additional six radiation therapy field 
treatments of a single treatment area 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 an additional six radiation therapy field treatments of a single treatment area 
have been met. Therefore, we decided that the Plan has to pre-approve an additional six radiation therapy field 
treatments of a single treatment area.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77003 and J3490 billed for date of service 
August 26, 2022. 
 
You asked the Plan to pay for procedure codes 77003 and J3490. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 77003 is 
bundled into payment for code 64493. Furthermore, payment for procedure code J3490 is included in the 
global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77003 
is a column II code to column I code 64493. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
Medicare rules also say that the Medicare approved amount for global surgery procedures includes payment for 
services related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 64493 provided on August 26, 2022. Separate payment cannot be made for 
procedure code J3490. Therefore, we decided that the Plan does not have to pay for procedure codes 77003 and 
J3490 billed for date of service August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 19, 2022, billed with 
codes 87637, 87641, 87651, 87798, 87581, 87481, 87486, 87498, 87500, 87532, 87556. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting reconsideration of the 
services. Please review the records attached. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. Panels with greater than 5 respiratory pathogens performed in the 
Part B outpatient setting are considered not medically reasonable and necessary. 
 
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 
April 19, 2022, billed with codes 87637, 87641, 87651, 87798, 87581, 87481, 87486, 87498, 87500, 87532, 
87556.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. The Plan denied your request. The 
Plan says this service is not reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that testing methods that include (real-time) duplex scans 
and Doppler ultrasound waveform with spectral analysis are covered for the indications listed in the Medicare 
rules section of this letter. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that a duplex scan of extracranial arteries is not medically reasonable and necessary for the 
enrollee. Our physician reviewer found the documentation does not support the rationale for repeating this 
imaging study. Guidelines do not support a need for carotid duplex scan extracranial bilateral study (93880). 
Our reviewer also found that at this time, cardiac doppler imaging would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service June 24, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. The Plan denied your request. The 
Plan says payment for codes 87481, 87653, and 87798 are bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that codes 87481, 87653, and 87798 are column II codes to column I code 
87801. The codes at issue have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87481, 87653, and 87798 billed for date of service June 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided May 3, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was submitted within the 
original limits set forth. The Plan denied your request. The Plan says according to Medicare Claims Processing 
Manual Chapter 34 Section 10.6.2, a corrected claim must be submitted within 1 year from the date of the 
initial determination or redetermination for any reason. 
 
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 emergency department visit was not filed until September 16, 2022. 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 an emergency department visit provided 
May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair option/accessory billed with code E2211-NU-
RT-LT-GY for date of service July 11, 2022. 
 
You asked the Plan to pay for code E2211-NU-RT-LT-GY. You say that You did not provide a specific 
argument for coverage. The Plan denied your request. The Plan says you did not bill this code with an 
appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories must be 
billed with modifier GA, GY, GZ, or KX.  Claim lines billed without one of these modifiers will be rejected as 
missing information. Items billed with modifier GY indicate that Medicare coverage criteria have not been met. 
If the GY modifier is not appropriate, the KX modifier must be added to the code.  
 
In this case, you billed the item in dispute with a GY modifier only, indicating that the item does not meet 
Medicare criteria.  You would have had to bill this code with the KX modifier in order for the code to be paid. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code E2211-NU-RT-LT-GY have not been met. Therefore, we decided that the Plan does not have 
to pay for the wheelchair option/accessory billed with code E2211-NU-RT-LT-GY for date of service July 11, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo (CPT code Q5120). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed two (2) of the preferred step therapy drug(s): 
Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), or Udenyca (pegfilgrastim-cbqv). The Plan states there 
is no indication the Plan's preferred drug(s) would likely be: less effective, and/or cause adverse effects for the 
enrollee.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the documentation does not support that two of the drugs, Neulasta (pegfilgrastim), Fulphila 
(pegfilgrastim-jmdb) or Udenyca (pegfilgrastim-cbqv) have been tried and failed. The documentation does not 
support that two of the following: Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb) or Udenyca 
(pegfilgrastim-cbqv) would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ziextenzo (CPT code Q5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs billed with code J3490 for July 20, 
2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 27096. Payment for code J3490 is included in the global surgical package for 27096. 
Therefore, we decided that the Plan does not have to pay for the unclassified drugs billed with code J3490 for 
July 20, 2022.