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

 
We decided that the Plan does not have to pay for code 47711 billed for date of service December 9, 2021. 
 
You asked the Plan to pay for code 47711. You did not provide a specific argument for coverage. The Plan 
denied your request. The Plan says code 47711 is not supported in the medical record. 
 
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 47711 is Excision of bile duct tumor, with or without 
primary repair of bile duct. 
 
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 code 47711. Our reviewer says that code 47711 is not 
supported in the medical record. Our reviewer found the operative report does not include documentation of 
excision of bile duct tumor, with or without primary repair of bile duct, per NCCI Policy "the physician 
performs excision of an extrahepatic bile duct tumor and reconstructs bile duct drainage".  Operative report 
documents "distal CBD, and the bile duct was skeletonized and we located and dissected the remnant cystic 
duct. There was a portion of remnant gallbladder as well, and we controlled the cystic duct and transected;  After the completion of the portal dissection, the bile duct, replaced right hepatic, left/proper and 
common hepatic arteries and portal vein were skeletonized and cleared of soft tissue".  Therefore, in this case 
code 47711 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 47711 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 47711 billed for date of service December 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that there is no support if the enrollee is sent home. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2021 billed with 
codes 81351, 81404, 81405, 81406, 81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says if one laboratory procedure evaluates multiple genes using a next generation 
sequencing 
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 CPT code. 
 
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 
August 2, 2021 billed with codes 81351, 81404, 81405, 81406, 81408, and 81479.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an office visit provided on July 20, 2021. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you went for an annual wellness 
visit, but the provider also billed for an office visit with advance care planning. You say that you should not 
have to pay the cost share on an office visit because you were only seen for a wellness visit. The Plan denied 
your request. The Plan says that the cost share applied was correct 
 
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 only submitted the 2022 Evidence of Coverage. The 2021 
Evidence of Coverage was requested but not received. Without the correct Evidence of Coverage, we cannot 
determine the cost you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided 
that the Plan has to waive the coinsurance for an office visit provided on July 20, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network comprehensive hearing test 
provided on May 4, 2022. 
 
You asked the Plan to waive the copayment for a hearing test. You say that you were told to keep your 
appointment in the hospital and bring your results to the Plan approved hearing specialist. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105 
copayment for in-network diagnostic procedures and tests at an outpatient hospital.  
 
You have been asked to pay a $105 copayment for a hearing test. This item/service falls within the Outpatient 
Hospital 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 an in-network 
comprehensive hearing test provided on May 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging, adenosine 
injection and contrast material provided on April 25, 2022. 
 
You asked the Plan to waive the cost for the myocardial perfusion imaging, adenosine injection and contrast 
material. You say that you do not feel you should have to pay this because you did not know why the provider 
was doing the procedure. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic radiological services including CTA, MRA, PET, SPECT and other nuclear medicine 
tests and a 20% coinsurance for Part B medications and contrast agents injected during a service.  
 
 
 
 You have been asked to pay a $75 copayment for the myocardial perfusion imaging and $108.69, which is 20% 
of the allowed amount for the adenosine injection and contrast material. The total amount you owe is $183.69 
($75 + $108.69 = $183.69). The services fall within the Outpatient diagnostic tests and therapeutic services and 
supplies 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 cost for the myocardial perfusion imaging, 
adenosine injection and contrast material provided on April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white cane for use by a blind person. 
 
You asked the Plan to pre-approve a white cane. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that a white cane for use by a blind person 
is more an identifying and self-help device rather than an item which makes a meaningful contribution in the 
treatment of an illness or injury. 
 
While a white cane may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a white cane for use by a blind person.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 27, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, spinal canal and contents, thoracic; without contrast material 
(CPT code 72146) and MRI spinal canal and contents, lumbar; without contrast material (CPT code 72148). 
 
You asked the Plan to pre-approve the MRIs. You say that the enrollee has new lumbar radiculopathy and their 
pain in the back is getting worse. The Plan denied your request. The Plan says that there are no new 
signs/symptoms to justify repeat MRIs of the thoracic and lumbar spine. The Plan states the request exceeds the 
enrollee's medical need and is not being performed in accordance with today's current medical standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRIs. Our physician reviewer 
found the enrollee has been given oral steroids in the form of a Medrol dose pack. The guidelines state that the 
administration of oral or injected steroids provides a valid indication for MRI without prior six (6) week trial of 
physical therapy (PT). 
 
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 MRIs have been met. Therefore, we decided that the Plan has to pre-
approve MRI, spinal canal and contents, thoracic; without contrast material (CPT code 72146) and MRI spinal 
canal and contents, lumbar; without contrast material (CPT code 72148).  
 
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 a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that given the previously submitted history, 
physical examination and the radiologic findings, the Intracept Procedure is medically necessary and supported 
by strong science. The Plan denied your request. The Plan says the requested Intracept procedure does not meet 
the requirements for approval. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has tried physical therapy, a home exercise program as well as aqua 
therapy. The enrollee's pain is also lessened with oral medication. This is considered an experimental/ 
investigational procedure at this time. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CAR-T Therapy (CPT code(s): Q2055 and 0540T) and 
the associated procedures. 
 
You asked the Plan to pre-approve the services. You say that the medication is necessary. The Plan denied your 
request. The Plan says CAR-T Therapy is not medically necessary for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 physician reviewer 
found the requested use of CAR-T Therapy (CPT code(s): Q2055 and 0540T) is not FDA-approved for the 
enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve CAR-T Therapy (CPT code(s): Q2055 and 0540T) and the associated procedures.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly. 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 provided on December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on April 28, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were choking at an 
establishment and they called the ambulance. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for an ambulance ride. This item/service falls within the 
ambulance 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 an ambulance ride 
provided on April 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on January 25, 2022, and 
January 26, 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 95720 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 95720 is electroencephalogram (EEG), continuous 
recording, physician or other qualified health care professional review of recorded events, analysis of spike and 
seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and 
report after each 24-hour period; with video (VEEG). 
 
We find that CPT code 95720 is not supported in the medical record. Specifically, the records show that 2 to 12 
hours of EEG recording was performed and there is a more appropriate code for these services. 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 testing services rendered on January 25, 2022, and January 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 20, 
2021. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and 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 procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, 
facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single 
or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they received a hemilaminectomy in 
the lumbar region during the 12 months prior to the index date. 
 
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 physician reviewer 
found detailed documentation is not evident that the enrollee is enrolled in a Medicare approved study. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the medical records provided do not meet the requirements listed in the 
NCD for Medicare coverage. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 
neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any 
method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; 
lumbar (CPT code 0275T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on May 14, 2022, to 
May 17, 2022. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you were seen for what you thought 
were allergies affecting your eyes. After four days of treatment, your eyes became worse. You were advised by 
another physician to stop the treatment. You do not believe that you or the Plan should be responsible for the 
bills. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for surgery services at an in-network specialists office. 
 
 
 
 
 You have been asked to pay a total of $135 for eye surgery ($45 copayment x 3 visits = $135). This 
item/service falls within the Physician/Practitioner services, including doctor's office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for surgical procedures of the eye provided on May 14, 2022 to 
May 17, 2022.