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

 
We decided that the Plan does not have to pay for surgical services (procedure codes 11056, 11721) provided 
to the enrollee on April 29, 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 provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 11056 and 11721 are not supported in the medical record. Specifically, CPT 27786 is a major procedure that has a global surgery period of 90 days, and was rendered on 3/17/22. These codes cannot 
be reported separately within 90 days of this surgery. 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 surgical services (procedure codes 11056, 11721) provided to the enrollee on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98927 billed for date of service May 15, 
2022. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the records do not include documentation of the billed code. 
 
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 98927 is osteopathic manipulative treatment (OMT); 5-6 
body regions involved. We find that CPT code 98927 is not supported in the medical record. 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 code 98927 billed for date of service May 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 17, 2022. 
 
You asked the Plan to pay for the consultation (D9310). You say that you called the Plan to ask for a list of in-
network dentists and were misinformed by the Plan's representative. The Plan denied your request. The Plan 
says the requested dental procedure code is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on August 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 14, 2022 to 
May 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 14, 2022 to May 
13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenodesis of long tendon of biceps provided to the enrollee 
on June 10, 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 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 code 23430 is "Tenodesis of long tendon of biceps." 
 
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 enrollee was being treated for 
bicipital tendinitis of the right shoulder. He underwent a right shoulder CTA hemiarthroplasty; long head 
biceps transfer to pectoralis major muscle belly; distal clavicle excision, open; and excision of subcutaneous 
cyst, greater than 3cm through shoulder on 6/10/22. The description of the procedure cites biceps in the groove 
was found to be significantly tendinotic. It was elevated out of the groove, whipstitched, and stitched in pectoralis major muscle belly medial to our tenotomy that was performed to aid in the exposure. The main 
proximal biceps tendon was removed. The procedure does not appear to include a tenodesis. Therefore, the 
records do not support that CPT 23430: tenodesis of long tendon of biceps 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for tenodesis of long tendon of biceps provided to the enrollee on June 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the enrollee's 
condition did not pose an immediate life threat. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 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 the billed services Our reviewer found that 
the enrollee presented to the hospital with abdominal pain for 2 days without vomiting, diarrhea, or 
constipation. His vitals were stable. His abdomen was soft, no mass, with generalized tenderness, no guarding 
or rebound and otherwise unremarkable. The computed tomography (CT) showed signs of possible 
duodenitis/peptic ulcer disease, two calculi in distal right ureter. He was given antibiotics and discharged home 
to follow-up with urology. There was no needed or performed emergency procedure or treatments and he was 
generally stable. The records do not show that the enrollee was treated for a problem of high severity or 
complexity. The records do not support the billed code, 99285. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99285 billed for date of service May 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on June 2, 2022. 
 
You asked the Plan to pay for the general health panel. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 80050 (general health panel) is considered a 
non-covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve the Vest Airway Clearance System. You say that it is imperative that the 
enrollee have access to the Vest for airway clearance. They have different mechanisms of action and 
complement each other of thorough clearance of secretions from the lungs. The Plan denied your request. The 
Plan says records do not show that the enrollee has the conditions above or a well-documented failure of 
standard treatments to adequately move fluid or mucous out of the airways. Under Medicare, the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 Vest Airway Clearance System. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found provided records 
do not document the enrollee has cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which 
a high frequency chest wall oscillation device may be covered. 
 
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 Vest Airway Clearance System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 7, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that a facet joint injection is medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injection does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injection. Our reviewer 
says that the requested facet joint injection is not medically necessary in this case. Our physician reviewer 
found that in this case the enrollee has neurogenic claudication for which she is being referred for further 
management. The review has determined that the requested facet joint injection does not meet the Medicare 
LCD coverage criteria. 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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CoreText or ProText (Whartons Jelly) injection. 
 
You asked the Plan to pre-approve a CoreText or ProText (Whartons Jelly) injection. You say that a CoreText 
or ProText (Whartons Jelly) injection is medically necessary. The Plan denied your request. The Plan says the 
requested CoreText or ProText (Whartons Jelly) injection 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 a CoreText or ProText (Whartons 
Jelly) injection. Our reviewer says that the requested CoreText or ProText (Whartons Jelly) injection is not 
considered medically reasonable and necessary. Our physician reviewer found this is considered an 
experimental/investigational procedure. Therefore, the request is deemed not medically 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 CoreText or ProText (Whartons Jelly) injection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CoreText or ProText (Whartons Jelly) 
injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that procedure code 36000 and 74183 were 
separately performed medically necessary procedures that were billed with appropriate modifiers. You say that 
the medical records should be reviewed, and the claim reprocessed for payment. 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 July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you have 
lymphedema. The Plan denied your request. The Plan says the requested device is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug is self-administered and is not covered under Part 
B. The Plan says that they do not administer Part D pharmacy benefits for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone.  
 
Benefits for Oxycodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 15, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service June 15, 2022, billed with 
code 99153.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service August 31, 2022. 
 
You asked the Plan to pay for the billed service. You say that the records support the procedure was performed. 
The Plan denied your request. The Plan says that code 76641 has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. The claim information shows that 2 units of code 76641 was billed. 1 unit of service was billed with 
modifier RT on one claim line and 1 unit of service was billed with modifier LT on the other claim line. Based 
on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure code 76641 billed for date of service August 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient procedure for right L5 foraminal stenosis via 
either L5 foraminotomies, or L2-S1 facetectomy and extension of fusion to S1 coded as 22840, 22632, 20930 
and 22853. 
 
You asked the Plan to pre-approve the inpatient surgery. You say that the records should support the necessity 
of the requested service. The Plan denied your request. The Plan says this request does not meet the criteria for 
medical necessity. 
 
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 inpatient surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures to include physical therapy. 
Additionally, dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. The formal diagnostic studies were not provided for review. 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. Therefore, the requested 
inpatient procedure for right L5 foraminal stenosis via either L5 foraminotomies, or L2-S1 facetectomy and 
extension of fusion to S1 coded with 22840, 20930, and 22853, in this case, is 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 the inpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient procedure for right L5 foraminal stenosis via either L5 foraminotomies, 
or L2-S1 facetectomy and extension of fusion to S1 coded as 22840, 22632, 20930 and 22853.