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

 
We decided that the Plan does not have to pay for the critical care and electrocardiogram (EKG) interpretation 
and report services rendered on July 11, 2021. 
 
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 procedure codes 99291 and 93010 are not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of code 93010 is electrocardiogram, 
routine ECG with at least 12 leads; interpretation and report only. 
 
We find that CPT codes 99291 and 93010 are not supported in the medical record. Specifically, there is no 
documentation of the first 30-74 minutes of critical care services to support code 99291. There is no 
documentation of an EKG interpretation and report to support code 93010. 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 critical care and electrocardiogram (EKG) interpretation and report services 
rendered on July 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair purchased on January 11, 2022. 
 
You asked the Plan to pay for the power wheelchair. You say that you would like to be reimbursed for this 
device. The Plan denied your request. The Plan says the criteria for coverage of the ordered device have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the power wheelchair purchased on 
January 11, 2022, have been met. Specifically, no medical records have been provided in this case to indicate 
the clinical criteria for coverage were met at the time of purchase. Therefore, we decided that the Plan does not 
have to pay for the power wheelchair purchased on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87633) provided December 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. The test was for 6 or more pathogens and is non-covered. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87633) provided December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95908, 95937 and 95955 billed on 
October 29, 2021. 
 
You asked the Plan to pay for procedure codes 95886, 95908, 95937 and 95955. You say that the enrollee's in-
network surgeon ordered services as a surgical requirement and were provided in an in-network facility. You 
say that these procedures are medically necessary for diagnosis and surgical treatment and the claim should be 
resolved. The Plan denied your request. The Plan says procedure codes 95886, 95908, 95937 and 95955 are not 
supported by the medical records submitted. 
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 95908 is nerve 
conduction studies; 3-4 studies. 
  The CPT Code Manual definition of code 95937is neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method. The CPT Code Manual definition of code 95955 is 
electroencephalogram (EEG) during non-intracranial surgery (eg, carotid surgery). 
 
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 95886, 95908, 95937 and 95955. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the medical record describes pedicle screw stimulation. CPT code CPT 95908 for nerve 
conduction studies is inappropriate for the service provided. Since the nerve conduction studies cannot be 
verified, procedure code 95886 would not be covered. The medical record also describes Train of Four testing. 
CPT code 95937 for neuromuscular junction testing is an inappropriate code to report for the service provided. 
In addition, the medical documentation does not include documentation of an electroencephalogram (EEG) 
during non-intracranial surgery. 
 
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 95886, 95908, 95937 and 95955 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95886, 95908, 95937 and 95955 billed on 
October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from December 9, 2021, 
through December 31, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says the service 
obtained was rendered by a provider who is not under contract with the health Plan and has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided from December 9, 2021, through December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3rd opinion to be provided by an orthopedic specialist. 
 
You asked the Plan to pre-approve a 3rd opinion to be provided by an orthopedic specialist. You say that you 
went online to do your own research and you found this orthopedic specialist and the office booked an 
appointment. The Plan denied your request. The Plan says a 3rd opinion is not medically necessary and does 
not meet the Plan's Medical Policy coverage criteria. 
 
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 3rd opinion to be provided by an 
orthopedic specialist. Our reviewer says that a 3rd opinion is not medically necessary. Our physician reviewer 
found that you have degenerative back pain. There is no clinical reason or need for a 3rd qualified opinion 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 a 3rd opinion to be provided by an orthopedic specialist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a 3rd opinion to be provided by an orthopedic 
specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a Group 3 power 
wheelchair have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options (K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections, platelet rich plasma, any site, including 
image guidance, harvesting and preparation when performed (Code 0232T). 
 
You asked the Plan to pre-approve injections, platelet rich plasma, any site, including image guidance, 
harvesting and preparation when performed. The Plan denied your request. The Plan says injections, platelet 
rich plasma, any site, including image guidance, harvesting and preparation when performed do not meet the 
Medicare coverage criteria. 
 
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 injections, platelet rich plasma, any site, 
including image guidance, harvesting and preparation when performed. Our reviewer says that platelet rich 
plasma injections are not medically necessary. Our physician reviewer found that based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the platelet rich 
plasma injections meet Medicare criteria for safe, effective and medically necessary. As stated in the Local 
Coverage Determination (L39071), the evidence is insufficient to determine the effects of platelet rich plasma 
on health outcomes for osteoarthritis. Drugdex/Micromedex has a strong recommendation against use 
of platelet rich plasma for osteoarthritis of the knee.  
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections, platelet rich plasma, any site, including image guidance, harvesting 
and preparation when performed have not been met. Therefore, we decided that the Plan does not have to pre-
approve injections, platelet rich plasma, any site, including image guidance, harvesting and preparation when 
performed (Code 0232T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 vaccination provided December 20, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccination. You say that this service was medically necessary. 
The Plan denied your request. The Plan says original Medicare is liable for payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment for COVID vaccinations 
administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS 
program. 
 
We looked at the file and Medicare rules. This service is covered through Original Medicare. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 vaccination have not been met. 
Therefore, we decided that the Plan does not have to pay for a COVID-19 vaccination provided December 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90832) provided February 
15, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for outpatient mental health services to be 
covered, the provider must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations, and the date of consultations in the 
patients medical record. 
 
We looked at the file and Medicare rules. There is no record of an attempt to consult the patient's primary 
physician. Based on this information, we decided that Medicare rules for coverage of the outpatient mental 
health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services (90832) provided February 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services (99310) provided September 10, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the claim was not filed timely. 
 
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 information provided by the plan does not show that the claim was 
submitted more than 1 year from the date of service. Therefore, we decided that the Plan has to pay for 
physician services (99310) provided September 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292, 81235, 81206, 81301, 81321) provided 
March 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for the panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81292, 81235, 81206, 81301, 81321) provided 
March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 2, 2021. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes (A5500) purchased on February 14, 2022. 
 
You asked the Plan to pay for the diabetic shoes. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these shoes who purchased from a provider 
who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic shoes (A5500) purchased on 
February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87640, 87641, 87798, 87801, 
87481, 87653, and 87651 provided on October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 87640 is a column II code to column I codes 87801 and 87641.  
We have also confirmed that code 87641, 87798, 87481, 87653, and 87651 are all column II codes to column I 
code 87801. This means the claim has not been billed with an appropriate modifier to bypass the edit. While 
these codes were billed with modifier -59, the medical records provided do not show that the service billed with 
the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the submitted documentation 
provided does not contain sufficient detail to support the billed charges. The records include laboratory results. 
However, the claim/order/lab requisition does not include what laboratory test was ordered/requested in order 
to validate the unlisted code billed. Therefore, this code cannot be verified. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87640, 87641, 
87798, 87801, 87481, 87653, and 87651 provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the repeat SI joint injection. You say that it is felt that this should be 
covered. The Plan denied your request. The Plan says the prior injection did not provide relief. Repeating this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a diagnostic SI block is considered positive when 
75% to 100% pain relief is achieved. Therapeutic injections may be considered reasonable and necessary after 
a positive diagnostic injection. 
 
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 repeat SI joint injection. Our 
reviewer says that the requested injection is not medically necessary.  Our physician reviewer found the enrollee is a male with low back pain and right sided sacroiliitis. On 2/1/22, 
he had an SI joint injection but did not achieve any pain relief. The request is to repeat the injection. The LCD 
criteria requires significant pain relief and significant duration of pain relief. This was not achieved; therefore, 
therefore, the request is considered not medically reasonable or 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 repeat SI joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat sacroiliac (SI) joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drainage of peritoneal abscess (49020) provided on May 
2, 2021. 
 
You asked the Plan to pay for the drainage of peritoneal abscess (49020). You say that the documentation 
should be reviewed, and the claim processed accordingly. The Plan denied your request. The Plan says 
procedure code 49020 is considered inclusive to CPT code 44160. 
 
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 49020 is a column II code to column I code 44160; however, 49020 
was billed with a modifier.  
 
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 drainage of peritoneal abscess (49020). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not support a distinct procedural service as the services were performed in 
same anatomical location. Therefore, this procedure would be inclusive to the primary 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 drainage of peritoneal abscess (49020) have not been met. Therefore, we 
decided that the Plan does not have to pay for the drainage of peritoneal abscess (49020) provided on May 2, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on February 11, 
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 there is no valid face-to-face encounter for the item. 
 
The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the 
beneficiary and their treating physician is required prior to prescribing durable medical equipment.  
 
We looked at the file and Medicare rules. The file shows that there is no documentation of an in-person, face-
to-face encounter for the services at issue. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis (LSO) rendered on February 11, 2022.