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

 
We decided that the Plan does not have to pay for procedure code 25115-RT-GC billed for date of service 
January 20, 2022. 
 
You asked the Plan to pay for procedure code 25115-RT-GC. You say that the medical records support 
payment of this code. The Plan denied your request. The Plan says procedure code 25115-RT-GC is not 
supported in the medical record. The operative report is not consisted with the extensive surgery and tedious 
removal of pathologic synovium. 
 
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 25115 is radical excision of bursa, synovia of the wrist or 
forearm tendon sheaths (tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) of the flexors. 
 
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 25115-RT-GC. Our reviewer says that this 
code is not supported in the medical record. Our reviewer found the operative report does not support a radical 
excision of bursa, synovia of the wrist or forearm tendon sheaths.  The operative report documents: "We then 
turned our attention to the flexor tendons Tenosynovitis of Flexor pollicis longus & Flexor Digitorum 
Profundus to the Index Finger was noted and excised using tenotomy scissors.  The tendons themselves were 
visually confirmed to be intact.  But they did have some moderate fraying but certainly much less than 50% of 
the tendon thickness.  The hand was taken through range of motion with passive tenodesis of the fingers 
intact". The operative report does not describe radical excision of bursa, synovia of the wrist or forearm tendon 
sheaths (per NCCI) "a longitudinal incision over the volar aspect of the distal forearm and wrist. Dissection 
exposes the flexor tendons of the wrist. The physician excises the bursa and any inflamed and hypertrophied 
tissues from around the tendons. The tendons are left intact, allowing them to glide better during wrist 
movement". The billed procedure was not found in operative report and cannot be verified.  
 
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 25115-RT-GC have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 25115-RT-GC billed for date of service January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36245-59-RT, 36247-LT, and 37244 billed 
for date of service October 27, 2021. 
 
You asked the Plan to pay for procedure codes 36245-59-RT, 36247-LT, and 37244. You say that these 
services were medically necessary and should be paid. The Plan denied your request. The Plan says these notes 
were not supported in the medical record. 
 
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 36245 is selective catheter placement, arterial system; 
abdominal, pelvic or lower extremity artery branch within a vascular family. The definition of code 36247 is 
selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family.  The definition of code 37244 is Vascular embolization or occlusion, inclusive of all radiological supervision 
and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention, 
for arterial or venous hemorrhage or lymphatic extravasation.   
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 36245-59-RT, 36247-LT, and 37244. Our 
reviewer says that these codes are not supported in the medical record. Our reviewer found for code 36245, the 
operative report describes selective catheter placement in the left gastric artery. In this case, CPT 36245 first 
order would be included in the higher vessel since it was through same access point. Therefore, separate billing 
of this procedure cannot be verified. For code 36277, the operative report describes selective catheter 
placement in the left gastric artery which is not a third order. In this case, this procedure cannot be verified. For 
code 37244, the operative report does not describe vascular embolization or occlusion for arterial or venous 
hemorrhage or lymphatic extravastion. The report cannot be cited as this procedure was not found in 
documentation. 
 
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 codes 36245-59-RT, 36247-LT, and 37244 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36245-59-RT, 36247-LT, and 
37244 billed for date of service October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the enrollee's trial spinal cord 
stimulator was approved with the same diagnosis codes/conditions. You say that the enrollee has tried and 
failed other treatments listed. The Plan denied your request. The Plan says the enrollee has not done enough 
physical therapy or chiropractic therapy to help. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation is covered for certain medical 
indications and when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord stimulator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found detailed documentation is 
not evident regarding the enrollee's chronic pain being caused by lumbosacral arachnoiditis; nerve root injuries, 
post-surgical or post-traumatic including that of post-laminectomy syndrome; complex regional pain syndrome 
I & II; phantom limb syndrome; end-stage peripheral vascular disease; post-herpetic neuralgia; plexopathy; 
intercostal neuralgia; cauda equina injury; or an incomplete spinal cord injury. Moreover, the documentation 
does not corroborate this being used as a late, if not last, resort for the chronic pain. The enrollee was seen by a 
neurologist who suggested a surgical procedure; however, was to hold off until after injections. There was no 
documentation to indicate that the enrollee was not a surgical candidate after the injections were provided. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 5, 
2022, to April 3, 2022. 
 You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment should be made for these 
services. The Plan denied your request. The Plan says SNF criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 5, 2022, to April 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
26, 2022, to March 5, 2022. 
 
You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment should be made for these 
services. The Plan denied your request. The Plan says Medicare SNF criteria were not met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 26, 2022, to March 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95910, 95937 and 95955 billed on 
November 10, 2021. 
 
You asked the Plan to pay for procedure codes 95886, 95910, 95937 and 95955. You say that the services were 
ordered by the in-network surgeon as a surgical requirement as the standard of care for the procedure. You say 
that the claim should be reprocessed based on the surgeon's requirement for the services. The Plan denied your 
request. The Plan says procedure codes 95886, 95910, 95937 and 95955 are not supported by the medical 
records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The CPT Code Manual definition of code 95910 is nerve 
conduction studies; 7-8 studies. The CPT Code Manual definition of code 95937 is neuromuscular junction 
testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The CPT Code Manual definition of 
code 95955 is electroencephalogram (EEG) during non-intracranial surgery (eg, carotid surgery). 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 95886, 95910, 95937 and 95955. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the technical report does not support nerve conduction studies, neuromuscular junction 
testing or an EEG during non-intracranial surgery being performed. The report describes Train of four testing 
and pedicle screw stimulation which would not be reported with 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 procedure codes 95886, 95910, 95937 and 95955 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95886, 95910, 95937 and 95955 billed on 
November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on January 12, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you would like to be reimbursed for 
this test. The Plan denied your request. The Plan says these tests were purchased prior to when the Plan was 
covering at-home COVID-19 tests. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests is an OTC item. While the Plan provides coverage for at-home COVID-19 tests, coverage was not available before February 1, 2022. Therefore, we decided that the Plan does not have to pay for the at-home 
COVID-19 tests purchased on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure is not medically reasonable and 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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the case file does not contain current medical records demonstrating that a Superion 
Interspinous Spacer (Veriflex) is medically reasonable and necessary for the enrollee in this case. 
Documentation of treatment measures tried and failed is lacking. 
 
 
 
 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires temporary use of 
oxygen when excursing energy over 80%. She currently has waited a month for dme request, longer wait would 
affect her financial state because she is not working due to this issue. The Plan denied your request. The Plan 
says the home ventilator you are requesting does not meet the requirements for approval. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has OSA and pulmonary 
hypertension with a dilated RV. She has exertional hypoxemia and is on oxygen with activity. The OSA is 
adequately treated with CPAP. There is no evidence of chronic hypoventilation. The enrollee does not have 
COPD, thoracic restrictive disease, or neuromuscular disease. Medicare does not cover a home ventilator for 
treatment of OSA. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve the ESI services. You say that the enrollee received 98% relief from the 
previous TFESI injection, and this request is for a second injection in a series of two. You say that it is 
medically necessary that the enrollee continue with her pain management therapy. The Plan denied your 
request. The Plan says the requested injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months.  
 
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 ESI services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found it has not been 3 months since the 
first injection.  Therefore, at this time, the request is deemed 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 ESI services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epidural steroid injection (ESI) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for facility ambulance transport provided to the enrollee on September 1, 2021.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee was being treated as an inpatient and transport was arranged for by the facility and billed in the facility claim. Maximus overturned the Plans denial as the case file did not contain the inpatient claim. The Plan requested a reopen and provided a copy of that claim.
The Plan is correct in the case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim shows this service was ordered as inpatient transport. Therefore, we decided that the Plan does not have to pay for facility ambulance transport provided to the enrollee on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), free soft 
tissue graft procedure (D4277), intraoral X-rays (D0210), and periodontal maintenance (D4910). 
 
You asked the Plan to pay for the dental services. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says these dental claims have processed 
correctly. 
 
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 comprehensive 
periodontal evaluation services and free soft tissue graft are not among those covered under this benefit. In 
addition, for the periodontal maintenance and intraoral X-rays the Plan has correctly processed these services 
with a 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), free soft tissue graft procedure (D4277), intraoral X-rays (D0210), and 
periodontal maintenance (D4910).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that daily skilled therapy is not medically reasonable or 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee continues to be at risk for falling and requires 
assistance with mobility, but this does not require the skilled services of a physical therapist. Therefore, the 
additional six physical therapy visits cannot be considered medically 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27355 and 27486 billed on January 9, 2022. 
 
You asked the Plan to pay for procedure codes 27355 and 27486. You say that the operative report clearly 
states the polyethylene was replaced which is a component of a total knee replacement. You say that this 
procedure meets criteria for coverage and the service should be paid. The Plan denied your request. The Plan 
says procedure code 97605 was approved, and procedure code 27335 is considered inclusive to procedure code 
27310. The Plan also says procedure code 27486 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27355 is arthrotomy, with synovectomy, knee; anterior 
AND posterior including popliteal area. The CPT Code Manual definition of code 27486 is revision of total 
knee arthroplasty, with or without allograft; 1 component. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 27355 and 27486. Our reviewer says that 
the documentation does not support the use of procedure code 27486 and modifier -59. Our reviewer found that 
the description of the service billed with procedure code 27486 is listed within procedure code 27335. In 
addition, modifier -59 would not be appropriate due to the procedures being performed on the same knee. 
 
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 codes 27355 and 27486 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 27355 and 27486 billed on January 9, 2022.