Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service March 2, 
2022. 
  You asked the Plan to pay for procedure code 11721. You say that the physician provided medically necessary 
services and the services meet professionally recognized standards of healthcare. You say that the claim should 
be processed for payment. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 code 11721 billed for date of service March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on April 5, 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 code 64634 is 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 64634 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64634 is not supported in the medical record. Specifically, there is no documentation of 
a paravertebral facet joint with imaging guidance for each additional facet joint. 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 pain management services rendered on April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
December 28, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each physical therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy (PT) services provided on December 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you dont know why you would 
have a copayment for each visit. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $30 
copayment for each visit for Medicare-covered occupational therapy, physical and/or speech and language 
therapy visits.  
 
You have been asked to pay $30 copayment for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Insertion of subcutaneous cardiac rhythm monitor 
(33285) and cardiac event recorder (C1764) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical information provided shows no recent episode of 
syncope. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has no 
history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on ECG monitoring. A recent 
randomized clinical trial found that continuous monitoring for atrial fibrillation with an implantable loop 
recorder (ILR) (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not 
superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke but 
without a known prior history of atrial fibrillation. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Insertion of subcutaneous cardiac rhythm monitor (33285) and cardiac event recorder 
(C1764) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 4, 
2021. 
 
You asked the Plan to pay for procedure code 93042. The Plan denied your request. The Plan says payment for 
code 93042 is bundled into payment for code 93010.  
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 93042 
is a column II code to column I code 93010. 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 code 93042 billed for date of service December 4, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery services you received on February 28, 2022. 
 
You asked the Plan to pay for the oral surgery services. You say that you were told these services could be 
covered under your medical benefits. The Plan denied your request. The Plan says these are not medical 
services, they are dental services.  Your dental benefit does not cover oral surgery. 
 
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. Your dental coverage is limited to oral exams, cleanings, and x-rays.  
The records show that the sole reason for the oral surgery you received was to prepare your mouth for dentures.  
Therefore, these services are purely dental in nature and cannot be covered under your medical benefits. 
Therefore, we decided that the Plan does not have to pay for oral surgery services you received on February 28, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your life may be jeopardy without rehab, and you 
don't have great support at home. You say that the service should be authorized. The Plan denied your request. 
The Plan says care can be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are functioning at a home care level with ambulation and transfer and there 
are no complex rehabilitation needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is a lack of documented syncope. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an implantable loop recorder (ILR). Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming (33285) for 
the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health physical therapy visits. 
 
You asked the Plan to pre-approve 9 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 9 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 home health physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
January 5, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each physical therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy (PT) services provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right carotid barostimulator implantation. 
 
You asked the Plan to pre-approve the implantation. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is found to be experimental, investigational and unproven. 
 
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 implantation. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Baroreflex stimulation devices have been considered potential alternative treatments for 
resistant hypertension and heart failure. There remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in 
this patients 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 the implantation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a right carotid barostimulator implantation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus Homologous Recombination Deficiency (HRD) 
test (81479) billed for date of service August 27, 2021. 
 
You asked the Plan to pay for a Tempus HRD test. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because there is 
no documentation to support genetic testing on the billed DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
 
  We find that CPT code 81479 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage of a Tempus HRD test have not been met. Therefore, we decided that 
the Plan does not have to pay for a Tempus HRD test (81479) billed for date of service August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transesophageal echocardiography (TEE) provided to the 
enrollee on April 6, 2022. 
 
You asked the Plan to pay for the TEE. You say that this was medically necessary and should be approved. The 
Plan denied your request. The Plan says there is no guidance on using TEE to check lead placement and 
position two years after the original procedure. 
 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 TEE. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the appropriateness and medical necessity of a TEE to assess pacemaker lead position two 
years following pacemaker placement. The patient has no symptoms, pacemaker function is noted to be intact, 
and the stated indication is to assess for functional tricuspid regurgitation. Clinical guidelines do not support 
carrying out a TEE in this setting. In summary, there is no supportive evidence for the medical necessity of a 
TEE in this this patients 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 the TEE have not been met. Therefore, we decided that the Plan does not have 
to pay for a transesophageal echocardiography (TEE) provided to the enrollee on April 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided March 
10, 2022, to March 12, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says the copayment was applied 
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 $75 for 
emergency room services.  
 
You have been asked to pay $75 for emergency room services. Emergency room services fall within the 
Emergency Care 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 emergency room 
services provided March 10, 2022, to March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on February 10, 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 procedure code 64634 is 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 64634 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64634 is not supported in the medical record. Specifically, there is no documentation of 
paravertebral facet joint destruction with imaging guidance, for each additional facet joint. 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 injection services rendered on February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the implantable loop reader. You say that the implantable cardiac monitor is 
requested to be placed after an alcohol septal ablation. The Plan denied your request. The Plan says the enrollee 
has hypertrophic cardiomyopathy (a disease in which the heart muscle becomes thickened) but the enrollee has 
not had any syncopal episodes (have not passed out). 
 
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 implantable loop reader. Our 
physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR 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 the implantable loop reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ILR (CPT code 33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with or without Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. Medicare does not cover a home ventilator when 
used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).