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

 
We decided that the Plan does not have to pay for code 29819-59-RT billed for date of service September 23, 
2021. 
 
You asked the Plan to pay for code 29819-59-RT. You say that the medical records support payment of this 
code. The Plan denied your request. The Plan says code 29819-59-RT is considered bundled into the payment 
for code 29827-RT. The -59 modifier is not supported and no separate payment is allowed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 29819-59-RT Our reviewer says that 
the use of the -59 modifier to allow for separate payment of code 29819 is not supported by the medical record. 
Our physician reviewer found the operative report documents "With traction provided by the PA, there were 
two loose bodies in the axillary recess visualized.  Using an arthroscopic grasper, these were removed in the 
entirety and they consisted of cartilage". Per American Academy of Orthopedic Surgeons "The rules for coding loose body removal in the shoulder (29819) are slightly different. To use that code, the loose body must be 
larger than 5 mm. When that occurs, coding 29827 (arthroscopic rotator cuff repair) with 29819-59 is 
permissible".  In this case, the operative report does not include sufficient documentation to confirm code 
29819 is a separate distinct service from the primary procedure performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29819-59-RT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 29819-59-RT billed for date of service September 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on December 4, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you should not 
have to pay for this service. The Plan denied your request. The Plan says the ambulance benefit is a 
transportation benefit. If you are not transported, no covered service has been provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 4, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization and ultrasound services (procedure code 
37225, 37233, 37253) provided to the enrollee on April 26, 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 the denied codes is: 
 
CPT 37225: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed 
 
 
 CPT 37233: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
CPT 37253: 
 
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 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 . Our reviewer says that the services at issue in this case were 
not supported by the medical records. Our reviewer found that in terms of CPT 37225, this codes for 
atherectomy with or without percutaneous transluminal angioplasty (PTA). Atherectomy of the superficial 
femoral artery (SFA) and the popliteal artery are not separately billable but considered one segment. Code 
37225 has already been approved; billing a second 37225 is not appropriate and not covered. In terms of CPT 
37233, this codes for atherectomy with or without PTA of an additional tibial artery after an initial artery 
atherectomy.  Coverage of 2 of the 3 tibial arteries have already been approved. There is documentation that 
the posterior tibial artery was patent with no documentation of stenosis. If there was no atheroma, atherectomy 
is not billable. Therefore, this code is inappropriate and not covered. In terms of CPT 37253, this codes for 
intravascular ultrasound of an additional vessel. This apparently has already been adjudicated and covered.  
 
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 revascularization and ultrasound services (procedure code 37225, 37233, 37253) provided to 
the enrollee on April 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the administration of influenza virus vaccine provided on 
February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the administration of influenza virus vaccine. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-
network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the administration of influenza virus vaccine 
provided on February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH offers the best opportunity for 
the enrollee to regain function and that a lower level of care would jeopardize any chance they have for an 
optimal outcome. The Plan denied your request. The Plan says this is not medically necessary, and continued 
acute hospital stay was offered, until the member could discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary at this time as the patient is not yet 
stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on June 3, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible to pay 
this because you have never had to pay for a CT scan before and you were not told there would be a copayment 
this time. 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 a $200 
copayment for each advanced imaging service.  
 
 
 
 
 
 
 You have been asked to pay $86.40 for a CT scan, which is less than the standard $200 copayment amount. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a CT scan provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided April 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you reconsideration of this determination 
and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied your request. The 
Plan says the genetic test, Tempus xF liquid biopsy test, requested does not meet the requirements for approval. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the testing in this case does not have FDA approval or clearance as a companion in 
vitro diagnostic, and an FDA-approved or FDA-cleared indication for use in the enrollee's cancer. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel, 51 or greater genes (81455) provided April 
26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the electroencephalogram (EEG) provided on March 27, 2022. 
 
You asked the Plan to pay for the EEG. You say that the service was medically necessary. The Plan denied 
your request. The Plan says that the EEG was not medically necessary. 
 
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 pay for the EEG. Our reviewer says that the EEG is 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation clearly supports that the EEG was medically reasonable and necessary for the enrollee in this 
case, to evaluate the enrollee's seizure event and to potentially guide further 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 EEG have been met. Therefore, we decided that the Plan has to pay for the 
electroencephalogram (EEG) provided on March 27, 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 99140 billed for date of service December 3, 
2021. 
 
You asked the Plan to pay for procedure code 99140. The Plan denied your request. The Plan says procedure 
code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
May 20, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
service provided. 
 
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.  
 
We looked at the case file and the Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of this service have not been met. Specifically, the codes provided on the claim form submitted do 
not indicate that you had a diagnosis of a subluxation of the spine. Therefore, you do not meet criteria for 
coverage of the service provided in this case. Therefore, we decided that the Plan does not have to pay for the 
chiropractic manipulative treatment (98941) provided on May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (57410, 52332) provided on March 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 57410 
is a column II code to column I code 52332 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Additionally, payment for 
code 52332 is included in the global surgical payment for the procedure (58952) provided on January 26, 2022. 
Code 58952 has a 90-day global period. Therefore, we decided that the Plan does not have to pay for the 
services (57410, 52332) provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a specialist visit on April 1, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for services obtained from a primary care 
provider.  
 
The Plan says you must pay a $30 copayment for a specialist visit. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for an office visit. The records show the office visit was 
provided by a family medicine physician at a family medicine office, which would not be considered a 
specialist.  Therefore, we decided that the Plan has to waive the copayment for a specialist visit on April 1, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466) humidifier, heated, (E0562) full face mask (A7030) and miscellaneous DME supply or 
accessory (A9999). 
 
You asked the Plan to pre-approve a ventilator and components. You say that you need the ventilator because 
you are in the throes of dying and you need this equipment. The Plan denied your request. The Plan says the 
provided records do not show that the enrollee meets the criteria. 
 
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 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has COPD with a recent hospitalization for exacerbation. Notes indicate the 
patient has chronic hypercarbic respiratory failure, with baseline PaCO2 (partial pressure of cardon dioxide) in 
50s to 60s, but ABG (arterial blood gas) results are not provided. If the enrollee does have chronic CO2 (carbon 
dioxide) retention, may benefit from BiPAP (bilevel positive airway pressure) with AVAPS (average volume 
assured pressure support) during sleep as an outpatient. But Medicare does not cover a ventilator when used as 
BiPAP. 
 
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 and components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466) 
humidifier, heated, (E0562) full face mask (A7030) and miscellaneous DME supply or accessory (A9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided January 25, 
2022. 
 
You asked the Plan to pay for the orthosis. You say that please see the enclosed purchase order, along with the 
Fed Ex delivery slip. The purchase order number is clearly listed on the Fed Ex slip. The Plan denied your 
request. The Plan says the records do not support service billed. 
 
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, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of 
service. The submitted proof of delivery indicates the item was shipped on December 29, 2021 and delivered 
on January 2, 2022. However, the billed date of service is January 25, 2022. 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 the lumbar-sacral orthosis (L0650) provided January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on April 29, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you should not be responsible to pay 
this. 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 a $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 
 
 You have been asked to pay a $150 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the MRI provided on April 29, 2022.