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

We decided that the Plan has to pre-approve surgical procedures on the heart and pericardium, surgical
procedures on the heart (including valves) and great vessel (33340).
You asked the Plan to pre-approve surgical procedures on the heart and pericardium, surgical procedures on the
heart (including valves) and great vessel. You say that the procedure is medically necessary. The Plan denied
your request. The Plan says that based on Medicare guidelines, percutaneous transcatheter closure of the left
atrial appendage (Watchman procedure - heart surgery) you are requesting does not meet the requirements for
approval.
The Plan follows Medicare rules. Medicare rules say that nationally covered indications are a suitability for
short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of
shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants.
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 surgical procedures on the heart and
pericardium, surgical procedures on the heart (including valves) and great vessel. Our reviewer says that LAAC
insertion is reasonable and medically necessary. Our physician reviewer found that it appears that this enrollee
would be a suitable candidate for LAAC treatment based on current guidelines. Note that guidelines also
require a qualifying surgeon and mandatory inclusion of the patient in a prospective, national, audited registry
that consecutively enrolls LAAC patients, and also tracks the annual outcomes for each patient for a period of
at least 4 years from the time of the LAAC. Predicated on the fulfillment of these criteria, it would appear that
LAAC insertion is reasonable and medically necessary in this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of surgical procedures on the heart and pericardium, surgical procedures on the
heart (including valves) and great vessel have been met. Therefore, we decided that the Plan has to pre-approve
surgical procedures on the heart and pericardium, surgical procedures on the heart (including valves) and great
vessel (33340).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services (95861, 95955, and 95908)
provided on July 30, 2021.
You asked the Plan to pay for codes 95861, 95955, and 95908. You say that the medical records support the
billing of codes 95861, 95955, and 95908 provided on July 30, 2021. The Plan denied your request. The Plan
says the medical records do not support the billing of codes 95861, 95955, and 95908 provided on July 30,
2021.
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 95861 is Needle electromyography; 2 extremities with or
without related paraspinal areas. The definition of code 95955 is Electroencephalogram (EEG) during
nonintracranial surgery (eg, carotid surgery). The definition of code 95908 is Nerve conduction studies; 3-4
studies.
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 codes 95861, 95955, and 95908. Our reviewer says that the
medical records do not support the billing of codes 95861, 95955, and 95908 provided on July 30, 2021. Our
reviewer found based on the documentation provided, for code 95861, the procedure report does not include
documentation of 5 or more muscles stimulated, therefore this procedure cannot be verified. For code 95955,
the procedure report documents "real-time monitoring". This procedure code is reported for "special EEG"
testing per CPT code book. The procedure report does not document additional EEG testing. For code 95908,
the procedure report describes pedicle screw stimulation, which is not considered nerve conduction studies.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 95861, 95955, and 95908 have not been met. Therefore, we decided that
the Plan does not have to pay for the neuromonitoring services (95861, 95955, and 95908) provided on July 30,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of vision frames provided on August 10, 2021.
You asked the Plan to pay for a second pair of vision frames. The Plan denied your request. The Plan says you
are allotted up to one pair of eyeglasses (lenses and frames) each year.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services up to one pair of eyeglasses (lenses and frames) every year.
We looked at the file and the Plan's rules. The file shows that you are allotted up to one pair of eyeglasses
(lenses and frames) each year. Therefore, we decided that the Plan does not have to pay for a second pair of
vision frames provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head and brain
(70450) provided on June 23, 2021.
You asked the Plan to pay for a CT scan of the head and brain. You say that the service at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head and brain (70450)
provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the
enrollee on September 21, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says 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. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the
enrollee on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser treatment (96920) provided on June 16, 2021.
You asked the Plan to pay for code 96920. You say that the medical records support the billing of code 96920
provided on June 16, 2021. The Plan denied your request. The Plan says the medical records do not support the
billing of code 96920 provided on June 16, 2021.
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 96920 is Laser treatment for inflammatory skin disease
(psoriasis); total area less than 250 sq cm.
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 code 96920. Our reviewer says that the medical records do
not support the billing of code 96920 provided on June 16, 2021. Our reviewer found the provider reported a
procedure code for treatment of psoriasis, which does not support this procedure code. In this case, an unlisted
code with appropriate documentation should be reported, as there is no specific code for the treatment of
Vitilgo.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 96920 have not been met. Therefore, we decided that the Plan does not
have to pay for the laser treatment (96920) provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis
without contrast material (74176) provided on September 28, 2021.
You asked the Plan to pay for the CT without contrast. You say that the enrollee had multiple exams on the
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI)
Procedure to Procedure (PTP) edit exists between 74177 and 74176. This PTP edit has a modifier indicator of
1, meaning that modifiers associated with NCCI are allowed; however, an appropriate NCCI modifier was not
billed with this PTP code edit.
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 74176
is a column II code to column I code 74177. 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 the computed tomography (CT) of the abdomen and pelvis
without contrast material (74176) provided on September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
May 27, 2021, to June 3, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the
services provided to the enrollee.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $390 copayment per day for days 1-5 of Inpatient hospital care.
The enrollee has been asked to pay a $1,950 copayment for five days of inpatient hospital services ($390 x 5 =
$1,950). This means that the enrollee has been asked to pay the correct amount based on the contract with the
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services
provided from May 27, 2021, to June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit received on October 16, 2021.
You asked the Plan to pay for the visit. You say that this is medically necessary and should be covered. The
Plan denied your request. The Plan says this is not a covered benefit.
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 a chiropractic office visit received on October 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 3,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied code remains not supported.
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 code G0483 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11) 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 drug testing services provided to the
enrollee on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the
enrollee on April 1, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied code remain not supported.
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 99291 is "Critical care, evaluation and management of
the critically ill or critically injured patient; first 30-74 minutes."
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a
time-based code. 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 critical care services (procedure
code 99291) provided to the enrollee on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study (93976) provided on October 11, 2021.
You asked the Plan to pay for the vascular study. You say that the enrollee had multiple exams on this date, and
records support these services were provided as billed. The Plan denied your request. The Plan says a National
Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edit exists between codes 76856 and 93976.
This PTP edit has a modifier indicator of 1, meaning that modifiers associated with NCCI are allowed.
However, an appropriate modifier was not billed with this PTP code edit.
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 93976
is a column II code to column I code 76856. 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 the vascular study (93976) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on October 11, 2021.
You asked the Plan to pay for the x-ray. You say that this service should be covered. The Plan denied your
request. The Plan says the provider in this case does not participate in Original Medicare. The Plan requires
that supplemental dental services be received from a Medicare participating provider in order to be covered by
the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Supplemental (i.e., routine)
dental services must be received from a Medicare participating provider in order to be covered by the plan.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from
providers who have opted out of Original Medicare are not covered under this benefit. The provider in this case
does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for the
intraoral x-ray (D0220) provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive metabolic panel (80053)
provided on August 16, 2021.
You asked the Plan to waive the copayment for the comprehensive metabolic panel. You say that the services
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the
services provided.
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 $10
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $10 copayment for a comprehensive metabolic panel. Comprehensive metabolic
panels fall 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 comprehensive metabolic panel (80053) provided on
August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code(s): 22869 and 22870).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.
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. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
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 June 11, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you believed that
you were unable to stop the bleeding when your toenail came off when you removed your shoe. You say that
after being treated by the emergency medical technicians (EMT) you declined to be transported to the hospital.
The Plan denied your request. The Plan says your Plan covers ambulance transportation only when you are
actually transported by ambulance. Since you were not transported by ambulance, the service is not covered
under your Plan.
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 June 11, 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 June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 Continuous Glucose Monitor.
You asked the Plan to pre-approve the Dexcom G6. You say that you would like reconsideration because the
requested continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says the
member is not insulin treated and does not meet prior authorization criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve the
Dexcom G6 Continuous Glucose Monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (64447) provided on October 15, 2021.
You asked the Plan to pay for an injection. You say that you billed the place of service code you were given.
The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when a physician/practitioner furnishes services
to an outpatient of a hospital, payment is made under the physician fee schedule at the facility rate.
Physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient
department (including in a provider-based department of that hospital) or under arrangement to a hospital shall,
at a minimum, report the off campus-outpatient hospital Place of Service (POS) code 19 or on campusoutpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face
encounter.
We looked at the file and Medicare rules. The service at issue was billed with the inpatient POS code 21, but
the record shows that the enrollee was an outpatient at the time of service. Based on this information, we
decided that Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan
does not have to pay for an injection (64447) provided on October 15, 2021.