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

 
We decided that the Plan does not have to pay for the shoulder arthroscopy with debridement (29823) provided 
on March 22, 2022. 
 
You asked the Plan to pay for the shoulder arthroscopy with debridement (29823). You say that the operative 
report supports the medical necessity, and the code is payable with the modifier billed. You say that payment 
should be reconsidered due to the medical necessity of the procedure. The Plan denied your request. The Plan 
says procedure code 29823 is 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 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
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 shoulder arthroscopy with debridement (29823). 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 describe extensive debridement in multiple areas where no 
other work was performed. Therefore, this procedure 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 the shoulder arthroscopy with debridement (29823) have not been met. 
Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy with debridement 
(29823) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a ranibizumab injection provided on 
March 30, 2022. 
 
You asked the Plan to waive the coinsurance for a ranibizumab injection. You say that you thought your 
copayment would cover the injection and then the medical services would be covered. The Plan denied your 
request. The Plan says you have been charged the correct coinsurance 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
You have been asked to pay $307.20, which is 20% of the allowed amount for the injection. The allowed 
amount is $1536.00 (20% x $1536.00 = $307.20). The injection falls within the for Medicare Part B 
Prescription Drugs 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 coinsurance for a ranibizumab injection provided on March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for IRF care. 
 
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 at the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach. While the enrollee may benefit from continued therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity alternate setting such as a skilled nursing facility. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. You 
have chronic functional loss and have impaired capacity to participate in intensive rehabilitation. wound care 
can reasonably done at a level of care lower than the IRF. You do not require frequent physiatry oversight as your rehabilitation needs are not complex. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use 
other than knee (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that the requested 
device will ensure that the enrollee can regain as much range of motion in her elbow as possible. The Plan 
denied your request. The Plan says the requested device is covered for enrollee's who have received a total knee 
replacement. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pre-approve a continuous passive motion exercise device for use other than knee (E0936).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service by a 
physician or other qualified health care professional (99442) provided on May 13, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the telehealth service. You say that the services were medically necessary. The 
Plan denied your request. The Plan says services from out-of-network providers are not covered unless 
preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the telehealth 
service at issue. We found no exception that would require the Plan to pay for the telehealth service. Therefore, 
we decided that the Plan does not have to pay for the telephone evaluation and management service by a physician or other qualified health care professional (99442) provided on May 13, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 8, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says providers must not unbundle the services 
described. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the gene panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on May 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
outpatient visit. We found no exception that would require the Plan to pay for the outpatient visit. The records 
provided for review do not show that the outpatient visit was urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the outpatient visit provided on May 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for technetium tc-99m tetrofosmin injection 
provided on March 15, 2022. 
 
You asked the Plan to waive the coinsurance for technetium tc-99m tetrofosmin injection. You say that 
diagnostic procedures are covered in full, therefore you should not be charged for anything. The Plan denied 
your request. The Plan says coinsurance 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 20% 
coinsurance for each Medicare-covered medical supply. You pay these amounts until you reach the out-of-
pocket maximum. Your provider may need to obtain prior authorization. 
 
  You have been asked to pay $44.44, which is 20% of the allowed amount for the technetium tc-99m 
tetrofosmin injection. The allowed amount is $222.20 (20% x $222.20 = $44.44). Technetium tc-99m 
tetrofosmin injection falls 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 coinsurance for technetium tc-99m tetrofosmin 
injection provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that with the new Medicare plan, 
the enrollee would need prior authorization. The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography (code 77067) and a bilateral 
breast tomosynthesis (code 77063) provided on April 11, 2022. 
 You asked the Plan to pay for the screenings. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the billed claim exceeds the maximum number of units of 
service. 
 
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 77067 and 77063 is 1. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
the screenings have not been met. Therefore, we decided that the Plan does not have to pay for a screening 
mammography (code 77067) and a bilateral breast tomosynthesis (code 77063) provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular gene panel testing provided on August 20, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says indication for 
testing is pre-symptomatic. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. Excluded from coverage are any services such as cardiovascular disease 
screening tests for the early detection of cardiovascular disease or abnormalities. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular 
gene panel testing provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI scan. You say that the MRI scan is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not want to participate in physical 
therapy and there was no x-ray taken; therefore, the MRI scan is not medically necessary at this time. 
 
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 an MRI scan. Our reviewer says that 
the MRI of the lumbar spine is not medically needed at this time. Our physician reviewer found that in this 
case, the record indicates that the enrollee has low back pain and hip pain. There are no red flag symptoms 
neurological examination is noted to be normal physical. No recent plain films are reported to have been 
performed and conservative treatment has not been attempted. The requested service is not medically necessary 
and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional payments for a wheelchair. 
 
You asked the Plan to pre-approve additional payments. The Plan denied your request. The Plan says that there 
are no more remaining rental payments needed. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors pay the fee schedule amounts on a 
monthly rental basis not to exceed a period of continuous use of 15 months. 
 
We looked at the file and Medicare rules. The file shows that only 13 months of payment have been made. 
Based on this information, we decided that Medicare rules for coverage of additional payments have been met. 
Therefore, we decided that the Plan has to pre-approve additional payments for a wheelchair.  
 
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 procedure codes 37248, 75822, and 75825 with modifier -59 
provided on April 14, 2022. 
 
You asked the Plan to pay for procedure codes 37248, 75822, and 75825 with modifier -59. You say that the 
medical records support the use of modifier -59 with codes 37248, 75822, and 75825. The Plan denied your 
request. The Plan says the medical records do not support the use of modifier -59 with codes 37248, 75822, and 
75825. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure codes 37248, 75822, and 75825 
with modifier -59. Our reviewer says that the medical records do not support the use of modifier -59 with codes 
37248, 75822, and 75825. Our physician reviewer found the documentation submitted was reviewed, and the 
use of modifier -59 with code 37248 is not supported. The operative report describes angioplasty and stent placement in the same vessel, in which stent placement was reported with code 37238. In this case, angioplasty 
would not be separately billed when stent placement is performed. 
 
The documentation submitted was reviewed, and the use of modifier -59 with code 75822 is not supported. The 
operative report describes intravascular stent placement with radiological supervision and interpretation was 
performed and reported with code 37238. In this case, interventional vascular procedures include 
angiograms/venograms, and therefore this procedure would not be reported separately. 
 
The documentation submitted was reviewed, and the use of modifier -59 with code 75825 is not supported. The 
operative report describes intravascular stent placement with radiological supervision and interpretation was 
performed and reported with code 37238.  In this case, interventional vascular procedures include 
angiograms/venograms, and therefore this procedure would not be reported separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37248, 75822, and 75825 with modifier -59 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 37248, 75822, and 75825 with 
modifier -59 provided on April 14, 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 you need LTACH care. The Plan denied 
your request. The Plan says you are receiving appropriate in-patient acute care and are currently unstable for 
transfer to an LTACH. 
 
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 that the documentation does not support that you have a need for complex medical 
treatment. You do not require services at the LTACH that are not available at the acute care hospital or the 
skilled nursing facility. The requested treatments are not medically necessary at the LTACH level of care. You 
have improved medically and can receive further care at the current acute care hospital or a lower level of care 
when deemed appropriate. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on January 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug test. You say that the service provided to the enrollee out of medical 
necessity, and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug test provided on January 19, 2022, by an 
out-of-network (OON) provider.