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

 
We decided that the Plan does not have to pay for the iliac revascularization (37220) and aortography (75625) 
provided on December 2, 2021. 
 
You asked the Plan to pay for the iliac revascularization (37220) and aortography (75625). You say that the 
medical records should be reviewed, and the claim reprocessed. The Plan denied your request. The Plan says 
procedure codes 37220 and 75625 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 code 37220 is revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. The CPT Code Manual 
definition of code 75625 is aortography, abdominal, by serialography, radiological supervision and 
interpretation.  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 iliac revascularization (37220) and aortography (75625). 
Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. 
Our reviewer found the operative report does not include enough documentation to confirm revascularization 
iliac artery with transluminal angioplasty has been performed. The operative report also does not include 
documentation of abdominal aortography by serialography. 
 
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 iliac revascularization (37220) and aortography (75625) have not been met. 
Therefore, we decided that the Plan does not have to pay for the iliac revascularization (37220) and 
aortography (75625) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to change the deductible to a copayment for a destruction of a lesion 
and a biopsy provided on April 14, 2022. 
 
You asked the Plan to change the deductible to a copayment for a destruction of a lesion and a biopsy. You say 
that you were told the provider was in-network and there would only be a copayment applied to your bill. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider, and the proper 
deductible was applied. 
  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 $550 
deductible which is the amount you have to pay out-of-pocket before we will pay our share for your covered 
medical services. Until you have paid the deductible amount, you must pay the full cost for most of your 
covered services. Once you have paid your deductible, we will begin to pay our share of the costs for covered 
medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the 
calendar year. The deductible does not apply to some services, including certain preventive services received 
both in-network and out of network. This means that we will pay our share of the costs for these services even 
if you haven't paid your deductible yet. 
 
The total amount paid towards the yearly deductible prior to the date of service was $81. Leaving a balance of 
$469 ($550 yearly deductible - $81 paid towards deductible) to pay for the yearly deductible. The total amount 
allowed for the date of service was $295.18 which was applied to the yearly deductible balance of $469. 
Therefore, the $295.18 was properly charged towards the yearly deductible amount. 
 
You have been asked to pay a $295.18 deductible for a destruction of a lesion and a biopsy. The deductible 
falls within the What is Your Plan Deductible 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 change the deductible 
to a copayment for a destruction of a lesion and a biopsy provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on January 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the rendering physician is a hospitalist 
physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says services from 
non-participating 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 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 subsequent hospital care provided on January 3, 
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 subsequent hospital care provided on January 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the rendering physician is a hospitalist 
physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says services from 
non-participating 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 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 subsequent hospital care provided on January 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve a SCS. You say that the enrollee's diagnosis is listed on the Medicare LCD 
and should be considered medically necessary. You say that spinal column stimulation is the best option for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show that the enrollee has not had a complete chiropractor evaluation, physical therapy evaluation, or 
trial for SCS. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered for certain 
medical indications and when 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 a SCS. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee does not have an evidence-
based indication for a SCS trial. The enrollee has not tried physical therapy recently. The request is deemed 
medically unreasonable and unnecessary. 
 
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 SCS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a spinal cord stimulator (SCS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement procedure. 
 
You asked the Plan to pre-approve a total knee replacement. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested procedure have not been met. 
 The Plan follows Medicare rules. The rules say that total knee replacement surgery is medically necessary in 
the circumstances listed 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 a total knee replacement. Our reviewer 
says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident in the case record regarding advanced joint disease 
demonstrated by radiographs or MRI (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint 
subluxation, joint space narrowing, avascular necrosis); failure of previous osteotomy; distal femur fracture; 
malignancy of the distal femur, proximal tibia, knee joint, or adjacent soft tissues; failure of previous 
unicompartmental knee replacement; avascular necrosis of the knee; or proximal tibia fracture. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
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 total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on January 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital care. You say that the rendering physician is a hospitalist 
physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says services from 
non-participating 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 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 subsequent hospital care provided on January 2, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral nutritional supplement product. 
 
You asked the Plan to pre-approve the oral nutritional supplement product. You say that this is necessary for 
your condition. The Plan denied your request. The Plan says nutritional supplements are not covered benefits 
when you do not have a feeding tube. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the oral nutritional supplement product.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy to be provided by a tertiary care center. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they do not have clinical information stating that the enrollee's care requires more 
advanced tests or treatments that unique to a tertiary setting and not available at a community level in a 
coordinated fashion. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve the services. Our physician reviewer found this regimen can be given by in-
network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the services. Therefore, we decided that the Plan does 
not have to pre-approve chemotherapy to be provided by a tertiary care center.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rotator cuff repair and biceps tenodesis. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you have not completed a three-month trial of doctor-ordered 
treatment and demonstrated that it has not helped. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Our 
physician reviewer found that your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rotator cuff repair and biceps tenodesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and therapy services provided by a 
chiropractor on April 15, 2021. 
 
You asked the Plan to pay for the office visit and therapy services. The Plan denied your request. The Plan says 
the only covered service by a chiropractor is manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and therapy services provided by a chiropractor on April 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central 
venous catheter (36556-59) provided on October 29, 2021. 
 You asked the Plan to pay for the insertion of non-tunneled centrally inserted central venous catheter. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan 
says the criteria for coverage does not support payment for 36556 separately from 93503. 
 
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 36556 is a column II code to column I code 93503; however, 36556 
was billed with a modifier.  
 
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 insertion of non-tunneled centrally inserted central 
venous catheter. Our reviewer says that the documentation does not support payment for CPT code 36556. Our 
reviewer found the procedure report does not support the Medicare criteria for reporting CPT 36556 with CPT 
93503.  Per the Centers for Medicare and Medicaid Services, "CPT 93503 (Insertion and placement of flow 
directed catheter (e.g., SwanGanz)) shall not be reported with CPT 36555-36556 (Insertion of non-tunneled 
centrally inserted central venous catheter) or CPT 36568-36569 (Insertion of peripherally inserted central 
venous catheter) for the insertion of a single catheter.  If a physician does not complete the insertion of one type 
of catheter and subsequently inserts another at the same patient encounter, only the completed procedure may 
be reported".  This guideline was referenced in the National Correct Coding Initiative Policy Manual Chapter 5.  
In this case, CPT 36556 was unbundled from CPT 93503. 
 
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 insertion of non-tunneled centrally inserted central venous catheter have not 
been met. Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled centrally 
inserted central venous catheter (36556-59) provided on October 29, 2021.
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 for the enrollee. 
 
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 the enrollee needs 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. Post 
hip fracture rehabilitation is not complex and does not require intensive therapy. Many persons rehabilitate at 
home. Those who cannot rehabilitate at home routinely do so in a skilled facility. The member has no condition which is a barrier or need for more intensive services than are usual care. Our physician reviewer found that the 
enrollee's 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with codes 75716-XU and 75625-XU for date 
of service February 9, 2022. 
 
You asked the Plan to pay for procedure codes 75716 and 75625. You say that these services were billed 
appropriately and are supported in the record. These services were billed with the XU modifier, so they should 
receive separate payment. The Plan denied your request. The Plan says the payment for these services is 
included in the payment for another service billed for this same date. Although a modifier was billed to bypass the NCCI edit, the medical records do not support that the modifier was used appropriately as these services 
were not separate and distinct from the primary 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, we have confirmed that codes 
75716 and 75625 are column II codes to column I codes 93458 and 37229; however, 75716 and 75625 were 
billed with a modifier.  
 
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 75716 and 75625. Our reviewer says that 
these services are not supported as reported in this case. Our reviewer found CPT code 75625 is not supported 
as a separate procedure from CPT code 93458. The operative report does not support that this was a separate 
and distinct procedure from the cardiac catheter, as a different problem is not being treated, for abdominal 
aortography. Therefore, the XU modifier reported is inappropriate in this case. Additionally, the operative 
report does not support extremity angiography as a separate procedure from the revascularization procedure, 
and therefore the XU modifier is also not supported for CPT code 75716. Therefore, these services are not 
eligible for separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for separate payment of procedure codes 75716 and 75625 have not been met. Therefore, we 
decided that the Plan does not have to pay for services billed with codes 75716-XU and 75625-XU for date of 
service February 9, 2022.