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

 
We decided that the Plan does not have to pay for the intravascular ultrasound coded 37253, and the 
angiography services coded 75716 provided from July 28, 2022, to August 1, 2022. 
 
You asked the Plan to pay for the intravascular ultrasound and the angiography services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed 
 
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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 
 
We find that CPT code 37253 is not supported in the medical record. Specifically, the operative report did not 
include documentation of intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or 
therapeutic intervention, including radiological supervision and interpretation, for each additional noncoronary 
vessel (listed separately in addition to code for primary procedure), for the amount of units (three). In this case, 
we have confirmed that code 75716 is a column II code to column I code 37231. This claim has not been billed 
with an appropriate modifier to bypass the edit. 
 
Based on this information, we decided that Medicare rules for coverage of the intravascular ultrasound and the 
angiography services have not been met. Therefore, we decided that the Plan does not have to pay for the 
intravascular ultrasound coded 37253, and the angiography services coded 75716 provided from July 28, 2022, 
to August 1, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical procedure codes 49561 and 49568 provided to the enrollee on 
July 22, 2021. 
 
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 that the records do not support the services billed. 
 
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 49561: 
 
Repair initial incisional or ventral hernia; incarcerated or strangulated 
 
CPT 49568: 
 
Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of 
debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral 
hernia repair) 
 
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 the patient had a hernia identified 
and repaired in the right lower quadrant at which time a separate right inguinal hernia was identified and also 
repaired. A mesh patch was used to repair the defect. The denied codes are detailed and supported by the 
operative report in the records. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical procedure codes 49561 and 49568 provided to the enrollee on July 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that specimens were processed per physician request. 
The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on July 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The 
documentation does not support that the enrollee has a history of osteoporosis-related fracture or that the 
enrollee has tried and failed zoledronic acid. The documentation does not support that zoledronic acid would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal decompression procedure (62380). 
 
You asked the Plan to pre-approve the spinal decompression procedure. You say that this service was 
medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the spinal decompression procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there were no physical examinations provided for review to demonstrate 
objective deficits. Moreover, there are only limited large-scale, long-term studies 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 spinal decompression procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal decompression procedure (62380).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not yet capable of returning to daily 
activities and need to stay longer. The Plan denied your request. The Plan says you no longer require skilled 
services on a daily inpatient basis and the continuation of SNF is not medically necessary. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI) at C7/T1 (62321). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee would like this service. The Plan denied 
your request. The Plan says that the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI after 14 days can be performed, using a 
different approach, level and/or medication if appropriate, with the rationale and medical necessity for the 
second ESI documented in the medical record. 
 
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 ESI. Our reviewer says that the 
requested ESI is medically necessary. Our physician reviewer found the criteria allows for a repeat ESI with a 
different approach or a different level after two weeks if satisfactory results were not obtained the initial ESI. 
Therefore, the reviewer found that the requested ESI is medically reasonable and necessary in this case. 
 
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 ESI have been met. Therefore, we decided that the Plan has to pre-approve 
an epidural steroid injection (ESI) at C7/T1 (62321).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553). 
 
You asked the Plan to pay for the continuous glucose monitor. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for 
a continuous glucose monitor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025), single vision lenses (V2100), and 
polycarbonate or equal lenses (V2784) provided on June 3, 2022. 
 
You asked the Plan to pay for the deluxe frames, single vision lenses, and polycarbonate or equal lenses. You 
say that under your policy, your eye exam is covered 100%, and there is a $200 deductible on glasses/contacts. 
You also say that you paid $111.15 for the glasses, and you received a notice from the Plan's vision department 
stating you should have only paid $71.17 for the glasses. The Plan denied your request. The Plan says this 
benefit has been exhausted. The Plan also says the vision center was contacted on January 4, 2023, about you 
being overcharged for the eyewear, and the Plan was advised that they are working on it, and the Plan was 
asked to stop calling. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 for the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the full $200 allowance was applied toward 
this purchase on June 3, 2022, you also received a 20% discount, and are only responsible for the remainder of 
$71.17. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames, single 
vision lenses, and polycarbonate or equal lenses have not been met. Therefore, we decided that the Plan does 
not have to pay for the deluxe frames (V2025), single vision lenses (V2100), and polycarbonate or equal lenses 
(V2784) provided on June 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247 and 75710 billed for date of service 
August 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that additional records were provided. The Plan 
denied your request. The Plan says the services are inclusive to the main procedure. 
 
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 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. The CPT Code Manual definition of code 36247 is selective catheter placement, 
arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within 
a vascular family.  
 
We find that CPT codes 36247 and 75710 are inclusive to procedure code 37228, revascularization, 
endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal 
angioplasty. Open and percutaneous interventional vascular procedures include operative angiograms and/or 
venograms which shall not be separately reported as diagnostic angiograms/venograms. The medical records 
provided do not show that the services billed with the -59 modifier were distinct procedural services. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 36247 and 75710 billed for date of service August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 25, 2022 to July 29, 
2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 
81405-2u, 81406 (2 units), 81407, 81408-(2 units), and 81479 (3 units).. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
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 
July 25, 2022 to July 29, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81403, 81404, 81405-2u, 81406 (2 units), 81407, 81408-(2 units), and 81479 (3 units)..
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 93010. You say that this code should not be bundled. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 12011.  
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 93010 
is a column II code to column I code 12011. 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 93010 billed for date of service September 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage for special supplemental benefit for the 
chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you believe that the SSBCI benefit should be 
covered int he state of Kentucky. The Plan denied your request. The Plan says based on the documentation 
submitted, the enrollee does not meet the SSBCI  criteria for expanded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve coverage for special supplemental benefit for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37221 billed for date of service November 
30, 2021. 
 
You asked the Plan to pay for procedure code 37221. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
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 37221 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 
procedure code 37221 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 37221 billed for date of service November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear protection plan provided on July 22, 2020. 
 
You asked the Plan to pay for the eyewear protection plan. You say that you were told that the current sale 
price was cheaper than using the plan discount. The Plan denied your request. The Plan says for the eyewear 
protection plan, it is not covered under plan. The Plan also says that per the 2020 EOC on pages 83-84, it states 
under routine vision, that they cover eye refractions during routine exams, eyeglass lenses and eye glass frames 
or contact lenses. The Plan also says that you received services outside of the plan benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers certain routine vision care services. The eyewear protection plan is excluded from 
this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover certain routine vision care services. 
The eyewear protection plan is excluded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of eyewear protection plan have not been met. Therefore, we decided that the Plan 
does not have to pay for eyewear protection plan provided on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 22, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency nerve ablation, Intracept procedure 
(64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting prior authorization 
for intraosseous ablation of the basivertebral nerve which is accomplished with the Intracept procedure. The 
Plan denied your request. The Plan says this procedure is experimental and investigational as there is not 
enough medical proof that shows the safety and efficacy of the Intracept procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the radiofrequency nerve ablation, Intracept procedure (64628, 64629).