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

 
We decided that the Plan does not have to pay for procedure code 95913 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 95913. You say that the services were reported correctly as 13 
studies were performed. The Plan denied your request. The Plan says that this service is not supported as billed, 
and CPT code 95911 for 10 nerve conduction studies would be more accurate in this case. 
 
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 95913 is Nerve conduction studies; 13 or more studies. 
 
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 code 95913. Our reviewer says that code 95913 is 
not supported in the medical record. Our reviewer found the procedure report does not support 13 or more 
studies. Each descriptor (code) from CPT codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913, can be reimbursed only once per nerve, or named branch of a nerve, regardless of the number of sites tested or the 
number of methods used on that nerve. For instance, testing the ulnar nerve at wrist, forearm, below elbow, 
above elbow, axilla and supraclavicular regions will all be considered as a single nerve. Motor and sensory 
nerve testing are considered separate tests. CPT code 95905 is payable only once per limb studied and cannot 
be used in conjunction with any other nerve conduction codes".  In this case, 10 studies are documented, and 
therefore a more appropriate code should be reported. 
 
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 code 95913 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95913 billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87481, 87640, 87653, and 87798 
billed for date of service August 18, 2021. 
 
You asked the Plan to pay for procedure codes 87801, 87481, 87640, 87653, and 87798. You say that the 
services were necessary and supported as billed. The Plan denied your request. The Plan says code 87801 is not supported in the medical record, and codes 87481, 87640, 87653 and 87798 are bundled into code 87801 which 
means they are not separately billable/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. 
 
In this case, the CPT Code Manual definition of code 87801 is Infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
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 87801, 87481, 87640, 87653, and 87798. 
Our reviewer says that code 89801 is not supported in the medical record. Our reviewer said the medical 
records were carefully reviewed, and no laboratory results of infectious agent detection by nucleic acid was 
found.  Therefore, this procedure cannot be verified. 
 
In addition, we have confirmed that codes 87481, 87640, 87653 and 87798 are column II codes to column I 
code 87801. 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. 
 
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 87801, 87481, 87640, 87653, and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87801, 87481, 87640, 87653, and 
87798 billed for date of service August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1902) provided March 1, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says a replacement device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, carriers 
may determine the reasonable useful lifetime of equipment but in no case can it be less than 5 years. 
 
We looked at the file and Medicare rules. The same item was provided in the last 5 years. There was no 
detailed written order describing why a replacement was needed. Based on this information, we decided that 
Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for an orthosis (L1902) provided March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with a metal crown for tooth #22. 
 
You asked the Plan to pre-approve white glass with a metal crown for tooth #22. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
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. The Plan covers crowns when 
the services are medically necessary and reasonable. 
 
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 white glass with a metal crown for 
tooth #22. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
documentation provided meets the criteria for coverage for a crown restoration for tooth #22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with a metal crown for tooth #22 have been met. Therefore, we 
decided that the Plan has to pre-approve white glass with a metal crown for tooth #22.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation provided on January 
31, 2022. 
 
You asked the Plan to waive the copayment for an outpatient observation. You say that you should only have 
an emergency room copayment, not an outpatient observation copayment. The Plan denied your request. The 
Plan says the copayment applied was 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 a $225 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $225 copayment for an outpatient observation. An outpatient observation falls 
within the Outpatient Hospital Observation 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 outpatient observation provided on January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271). 
 You asked the Plan to pre-approve Pembrolizumab. You say that the requested chemotherapy is medically 
necessary. The Plan denied your request. The Plan says Pembrolizumab is being administered as part of a 
clinical trial. Original Medicare is liable for payment for this service. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Pembrolizumab as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (19380) provided December 2, 2021. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not correctly billed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 19380 is 1. You billed 2 units of this code, exceeding the MUE. The code 
was not billed correctly for a bilateral procedure. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (19380) provided December 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enoxaparin sodium. 
 
You asked the Plan to pre-approve Enoxaparin sodium. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enoxaparin sodium.  
 
Benefits for Enoxaparin sodium may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on December 22, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says air ambulance transport was not medically 
necessary. There is no evidence as to why the patient could not be treated at the original facility.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that air ambulance services were not medically necessary. Our physician reviewer found the 
documentation does support that the patient suffers from an illness or injury that contraindicates transportation 
by any means other than ambulance. The patient was diagnosed with myocardial infarction at the originating 
hospital. The documentation does not support that the patient's condition was such that the time needed to 
transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's 
survival or seriously endangered the patient's health. The documentation does not support that the transferring 
hospital did not have adequate facilities to provide the medical services needed by the patient. The originating 
hospital is recognized as a Chest Pain Center by the American College of Cardiology. It is unclear why the 
patient required transportation from a facility that is designated as a treatment facility for myocardial 
infarction.  
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81599) provided October 11, 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 to report a Molecular Diagnostic Test service, 
providers must submit the appropriate DEX  Z-code. 
 
We looked at the file and Medicare rules. The claim did not include an appropriate DEX Z-code. 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 (81599) provided October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior cervical discectomy and fusion (20931, 22551, 
22845). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary for the enrollee's 
condition. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no objective examinations provided for review to corroborate the pathology. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anterior cervical discectomy and fusion (20931, 22551, 22845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (K0553) provided January 15, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for diabetic supplies (K0553) provided January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided from 
February 18, 2022, through April 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services do not meet Medicare criteria 
for payment. 
 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the Medicare rules 
for coverage of the acupuncture services provided have not been met. Specifically, you provided treatment to 
the enrollee as an acupuncturist who was not under the supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided from February 18, 2022, through April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the patient is 
not yet stable and as it would not be clinically advantageous at this time. Completion of care at the current 
facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments (97810, 97811). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your request for acupuncture treatment does not 
meet criteria for coverage. 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of the acupuncture services have not been met. Specifically, you have requested acupuncture for the 
treatment of asthma, vocal cord dysfunction, and acid reflux. However, these conditions do not meet criteria for 
coverage of acupuncture treatment by the Plan. Therefore, we decided that the Plan does not have to pre-
approve acupuncture treatments (97810, 97811).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 13, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the member is 82 years old and thought she 
was having a reaction to a medication she was taking for a urinary tract infection.  She lives in an assisted 
living facility and had no other means of transport. The Plan denied your request. The Plan says ambulance 
transportation was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same 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 pay for the ambulance services. Our reviewer says 
that these ambulance services were not medically necessary. Our physician reviewer found the members 
presenting symptoms did not meet prudent layperson criteria for emergency care. The member was treated for a 
urinary tract infection. Vital signs were stable. There was no notable worsening of symptoms. The 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this member. The member could have been 
transported by other means. The documentation does not support that the member needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport on 2/13/22. There was no documentation of need for monitoring or intervention. The documentation 
does not support that the ambulance transport was medically reasonable and necessary for the member.  
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on February 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. 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. 
 
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 Actemra. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.