Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheal suction catheter (code A4624) provided on 
March 1, 2022. 
 
You asked the Plan to pay for the tracheal suction catheter. You say that the patient has malignant neoplasm of 
the tongue and dysphagia. The Plan denied your request. The Plan says the patient does not meet criteria for 
coverage. The Plan must follow Medicare rules. Medicare rules say that code A4624 is not covered unless the 
patient has a tracheostomy.  The records provided do not show that the patient in this case has a tracheostomy. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the tracheal suction catheter have not been met. Therefore, we decided that the Plan does not have 
to pay for the tracheal suction catheter (code A4624) provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment that was 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 $50 
copayment for x-rays (such as plain film x-rays like a chest x-ray or bone x-ray) in an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic Test 
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 copayment 
for an x-ray provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx test provided to the enrollee on 
March 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the required DEX Z-CodeTM was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 The case file does not show any evidence of a valid unique identifier for this test. 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 pay for the FoundationOne CDx test provided to the enrollee on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87798, and 87801 
billed for date of service October 26, 2021. 
 You asked the Plan to pay for procedure code 87481, 87640, 87653, 87798, and 87801. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87640, 
87653, and 87798 are bundled into payment for code 87801. The Plan also says that code 87801 is not 
supported by the documentation. 
 
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 codes 
87481, 87640, 87653, 87798, and 87801 are column II codes to column I code 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit. We find that CPT code 87801 is not supported in the 
medical record. Specifically, this code represents multiple organisms. The medical records submitted do not 
indicate which organisms are represented by the billed code. Therefore, the billed code, units and appropriate 
use of the 91 modifier cannot be verified. 
 
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 codes 87481, 87640, 87653, 87798, and 87801 billed for date of service 
October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 10, 2022. 
 
You asked the Plan to pay for the serivces. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation provided does not support open treatment of distal radial extra-articular 
fracture or epiphyseal separation; with internal fixation of 3 or more fragments. 
 
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 25609 is "Open treatment of distal radial intra-articular 
fracture or epiphyseal separation; with internal fixation of 3 or more fragments." 
 
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 serivces. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not clearly support 
this code. The enrollee underwent an open reduction, internal fixation of left comminuted intra-articular distal 
radius fracture on 3/10/22. The procedure note cited Two more cortical screws were placed proximally for a 
total of 3 cortical screws in the shaft. This in itself does not clearly evidence that 3 fragments were internally 
fixated during the procedure ."(despite the notes indicating comminuted, intra-articular fracture.) Therefore, the 
records do not clearly support that CPT 25609- open treatment of distal radial intra-articular fracture or 
epiphyseal separation, with internal fixation of 3 or more fragments- was actually rendered in this case.  
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 serivces have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on March 10, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on May 7, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee did not enroll in the hospice benefit until 
after the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on May 1, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) 
provided on May 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on May 16, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have submitted medical records for medical 
necessity. The Plan denied your request. The Plan says as a member of their plan, enrollees must use network 
providers. 
 
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 an office visit (99215) provided on May 16, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service December 2, 
2021. 
 
You asked the Plan to pay for procedure code 99291. You say that the records support the necessity of this 
service. The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 
36556. 
 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 99291 
is a column II code to column I code 36556. 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 99291 billed for date of service December 2, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on May 10, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $45 
copayment for each specialist visit for Medicare-covered services. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for office visit. Office visits fall 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 office visit on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve facet injections. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria 
are met. 
 
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 facet injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has an untreated 
radiculopathy. Therefore, the request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on January 12, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you fell and the paramedics 
came to assist you in standing up and getting back on your power wheelchair. You believe this service should 
be covered. The Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services provided on 
January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the ultrasound study of arm or leg 
veins with compression and maneuvers (93970) provided on November 12, 2021. 
 
You asked the Plan to waive the cost share amount for the diagnostic imaging. You say that you want to appeal 
this charge. The Plan denied your request. The Plan says the cost share 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 a $90 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $90 copayment for the diagnostic imaging. The diagnostic imaging 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 cost share amount for the ultrasound study of arm or leg veins with compression and 
maneuvers (93970) provided on November 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transluminal balloon angioplasty. 
 
You asked the Plan to pre-approve transluminal balloon angioplasty. 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 follows Medicare rules. Medicare rules say that endovenous stents is covered when specific criteria 
are met. 
 
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 transluminal balloon angioplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found guidelines would not 
support an indication for transluminal venous angioplasty and stent placement. At the current time, the 
requested procedures are not considered to be medically necessary in this 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 transluminal balloon angioplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transluminal balloon angioplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on May 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the enrollee was being seen for chronic shoulder 
pain. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
  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 outpatient visit provided on May 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure codes 95908, 95886, 95937) 
provided to the enrollee on April 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the enrollee 
underwent spinal surgery and intraoperative neuromonitoring services were provided. The member underwent 
placement of pedicle screws. The screws were stimulated, and a claim was submitted for provision of a nerve 
conduction study (NCS). However, it has been advised in the CPT manual (and related publications) that 
pedicle screw testing is considered to be an inherent part of electromyography (EMG) services. Therefore, as 
pedicle screw testing is not consistent with NCS (CPT 95908), this code is not supported. As nerve conduction 
study is not supported, then CPT 95886 would not have been considered to have been coded appropriately and 
is otherwise not supported. In terms of CPT 95937, this was coded for train of four services. Train-of-four 
monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked 
potentials (MEP) and, therefore, is not separately reportable. Therefore, this service would also not be 
supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurology services (procedure codes 95908, 95886, 95937) provided to the enrollee on April 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve SI joint injections. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 SI joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found if the first SI joint injection did not provide significant pain relief, then a repeat block 
unlikely to do so. The request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sacroiliac (SI) joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization. 
 
You asked the Plan to pre-approve a left heart catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records provided do not support the rationale for this invasive 
imaging study. The enrollee had 3 normal radionuclide stress tests in the past, most recently in 2021. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollees 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization.