Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Transcranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that the services are necessary. The Plan denied your request. 
The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 TMS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case.  Our physician 
reviewer found based on review of the records provided and utilizing the coverage determination specifically 
for Transcranial Magnetic Stimulation ((TMS) requires the confirmed diagnosis to be Severe Major Depressive 
Disorder Single or Recurrent as well as resistance the treatment with pharmacologic agents as evidenced by 
lack of clinical significant response to 4 trials of pharmacologic agents in the current depressive episode from 
at least two different agent classes along with concurrent documented psychotherapy. Documentation presented 
shows this enrollee has successfully been treated with Transcranial Magnetic Stimulation (TMS). Utilizing the 
information, this enrollee presented for the requested Transcranial Magnetic Stimulation (TMS) and utilizing 
the requirements for Transcranial Magnetic Stimulation (TMS) the enrollee does meet the criteria for the use of 
Transcranial Magnetic Stimulation (TMS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have been met. Therefore, we decided that the Plan has to pre-approve 
Transcranial Magnetic Stimulation (TMS).  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a colonoscopy (procedure codes 45381 and 45385) provided to the 
enrollee on July 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 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 45381: 
 
Colonoscopy, flexible; with directed submucosal injection(s), any substance 
 
CPT 45385: 
 
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that per the CPT Assistant, January 2017, 
volume 27, issue 6, page 6, a submucosal injection and snare removal of a polyp are reported with 45381 and 
45385. An endoscopic mucosal resection (EMR) requires 3 components, a submucosal injection to lift the 
lesion, demarcation of the lesion by a technique such as ligation or cautery, and resection of the polyp. If all 
three components are not performed, it is not appropriate to report an EMR procedure and the services 
performed (45381 and 45385) are separately reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for a 
colonoscopy (procedure codes 45381 and 45385) provided to the enrollee on July 8, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound scans of extracranial arteries (93880, 93882). 
 
You asked the Plan to pre-approve ultrasound scans of extracranial arteries. You say that the requested services 
are a necessity for your care. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 ultrasound scans of extracranial 
arteries. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that you reported symptoms of dizziness. There was an orthostatic 
component to your dizziness noted. Your neurological exam was otherwise noted to have been non-focal. 
There was no documentation of a carotid bruit on exam.  
 
Your primary complaint was one of dizziness. There were no other localizing neurologic signs or symptoms 
noted in the complaint or on examination, nor was there anything suggesting that ischemia or altered blood 
flow are present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound scans of extracranial arteries have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasound scans of extracranial arteries (93880, 93882).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910), fluoride (D1206), and 
unspecified preventive services (D1999 x 3) provided on September 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says that an Evidence of Benefits (EOB) was not received from your primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the periodontal maintenance (D4910), fluoride (D1206), and 
unspecified preventive services (D1999 x 3) provided on September 20, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service is supported as billed. 
 The Plan denied your request. The Plan says code 88305 is not appropriate to report the service provided. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 88305. Our reviewer says that code 88305 is 
not supported in the medical records provided. Our reviewer found the documentation does not support a level 
IV examination of surgical pathology specimen. Documentation is missing the accessioning of the specimen 
and examining each and every specimen to include where the specimen came from, and review of features 
observed with and without a microscope like color and shape. The report also does not offer a detailed review 
of all specimens. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88305 billed for date of service July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 (2 additional units) billed for date of 
service January 6, 2022. 
 
You asked the Plan to pay for 2 additional units of code 87481. You say that these labs were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says they have 
agreed to pay for codes 87641, 87653, 87500, 87640, 87798 and 3 units of 87481; however, the number of 
units billed for code 87481 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 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 2 additional units of code 87481 Our 
reviewer says that these services are not supported in the medical record. Our physician reviewer found the 
laboratory report documents, "Candida albicans Not Detected; Candida dubliniensis Not Detected: Candida 
lusitaniae Not Detected," which accounts for three units. In this case additional units cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional units of code 87481 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87481 (2 additional units) billed for date of service January 6, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluations without medical services 
provided from May 26, 2022, to July 13, 2022. 
 
You asked the Plan to pay for psychiatric diagnostic evaluations without medical services. The Plan denied 
your request. 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 Plan says that the Plan has also 
determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychiatric diagnostic evaluations without medical services 
provided from May 26, 2022, to July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition solution (B4197) billed for dates of 
service from June 22, 2022, to June 28, 2022. 
 
You asked the Plan to pay for parenteral nutrition solution. You say that the parenteral nutrition solution at 
issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not identify the items delivered. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for parenteral nutrition solution (B4197) billed for dates of service from June 22, 
2022, to June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in intelligent volume assured pressure support mode which could be 
provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support 
and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to 
provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care and hospital discharge day 
management services provided on August 2, 2022 to August 3, 2022. 
 You asked the Plan to pay for the subsequent hospital care and hospital discharge day management services. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says the record 
does not support that these services were more than 30 minutes in duration. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that Original Medicare, not 
the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims 
related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for 
these services. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care; more than 30 minutes. 
 
We find that CPT code 99233 billed for date of service August 2, 2022 is not supported in the medical record. 
Specifically, the record does not show that the subsequent hospital care service was more than 30 minutes in 
duration. The enrollee was under the Medicare hospice benefit for August 3, 2022; therefore, the Plan is not 
responsible for payment of this service. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care and hospital discharge day management service provided on  August 2, 2022 to 
August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a 
clinical trial of the device. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection(s), anesthetic agent(s) and/or 
steroid (64416) ultrasonic guidance for needle placement, imaging supervision and interpretation (76942) and 
anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, 
acromioclavicular joint, and shoulder joint; not otherwise specified (01630) provided July 25, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic injection services. You say that although your 
care was authorized, it was judged out of network and led to a 50% copay for you. This care, however, was not 
available in-network. The Plan denied your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for out of network surgery services.  
 You have been asked to pay $3,962.37 for the diagnostic injection services. This item/service falls within the 
Outpatient surgery, including services provided at hospital, outpatient facilities and ambulatory surgical centers 
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 the injection(s), anesthetic 
agent(s) and/or steroid (64416) ultrasonic guidance for needle placement, imaging supervision and 
interpretation (76942) and anesthesia for open or surgical arthroscopic procedures on humeral head and neck, 
sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified (01630) provided 
July 25, 2022.