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

We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937, the short-latency somatosensory evoked potential study coded 95938, and the central motor evoked potential study coded 95939 provided on November 16, 2021.

You asked the Plan to pay for the neuromuscular junction testing, the short-latency somatosensory evoked potential study, and the central motor evoked potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 CPT code.

We find that CPT codes 95937, 95938, and 95939 are not supported in the medical record. Specifically, these items were billed without an appropriate diagnosis code. Somatosensory Evoked Potentials and Responses (SEPs/SERs) testing is indicated to evaluate coma, degenerative non-traumatic spinal cord lesions, hereditary spastic paraplegia, intraoperative monitoring, multiple sclerosis, myoclonus, other diseases of myelin, spinal cord trauma, spinocerebellar degeneration, subacute combined degeneration, and syringomyelia. This means these services were billed without a diagnosis that is covered. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing, the short-latency somatosensory evoked potential study, and the central motor evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937, the short-latency somatosensory evoked potential study coded 95938, and the central motor evoked potential study coded 95939 provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography coded 95885, the 
neuromuscular junction testing coded 95937, and the nerve conduction studies coded 95908 provided on 
January 12, 2022. 
 
You asked the Plan to pay for the needle electromyography, the neuromuscular junction testing, and the nerve 
conduction studies. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services billed are not supported by the documentation. 
 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 95885, 95937, and 95908 are not supported in the medical record. Specifically, the 
operative report did not include documentation of a limited needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; 
(listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified. The 
operative report did not include documentation of neuromuscular junction testing (repetitive stimulation, paired 
stimuli), per each nerve, by any 1 method; therefore, code 95937 cannot be verified. The operative report did 
not include documentation of nerve conduction studies; for 3-4 studies; therefore, code 95908 cannot be 
verified. 
 
Based on this information, we decided that Medicare rules for coverage of the needle electromyography, the 
neuromuscular junction testing, and the nerve conduction studies have not been met. Therefore, we decided 
that the Plan does not have to pay for the needle electromyography coded 95885, the neuromuscular junction 
testing coded 95937, and the nerve conduction studies coded 95908 provided on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy services coded 29874 and 29875 and the 
arthrocentesis services coded 20610 provided on October 6, 2021. 
 You asked the Plan to pay for the arthroscopy services and the arthrocentesis services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. In this case, we have confirmed that code 29874 
is a column II code to column I code 29875 with a modifier indicator of 0. The column II code is therefore not 
payable. We find that CPT code 29875 is not supported in the medical record. Specifically, a synovectomy to 
clean up a joint on which another more extensive procedure is performed is not separately reportable. 
We find that CPT code 20610 is not supported in the medical record. Specifically, global surgery rules prevent 
separate payment for postoperative pain management when provided by the physician performing an operative 
procedure. Per the operative report the Marcaine and Duramorph were given for postoperative pain control. 
 
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 arthroscopy services coded 29874 and 29875 and the arthrocentesis services coded 
20610 provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for outpatient surgery
services and neurostimulator implantation provided on August 20, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was applied based on the services provided and the
Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a $100 copayment for
outpatient surgery services and a 20% coinsurance for prosthetic devices. Devices (other than dental) that
replace all or part of a body part or function are a prosthetic device. For example, when you have a device such
as a pacemaker, colostomy bag, or in your case a neurostimulator implanted into the body to take the place of a
part of the body that no longer functions or requires assistance, such as pain for nerve damage, it is not
considered traditional durable medical equipment and it's considered a prosthetic device. 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 or reduce the cost share charged for outpatient hospital services and neurostimulator
implantation provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81206, 81235, and 81321 provided 
on October 19, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, the 
documentation does not support that the genetic testing was ordered/approved by the ordering provider. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing coded 81206, 81235, and 81321 
provided on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on October 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing will guide appropriate medical 
management of the enrollee. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The claim information shows the gene panel was billed with multiple codes. If a single procedure is performed, 
only one code with one unit of service may be reported for the procedure. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the gene panel provided on October 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve goniotomy services (65820). 
 
You asked the Plan to pre-approve goniotomy services. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
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 goniotomy services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a diagnosis of primary open-angle glaucoma of the left eye, mild 
stage. On June 23, 2022, it is documented that the enrollee has been using Latanoprost ocular medication once daily since May 8, 2014. The enrollee's intraocular pressure was stable, and the Plan was to continue the same 
medications. The enrollee was ready for cataract surgery. In this case, as the approved Current Procedural 
Terminology (CPT) code includes insertion of an intraocular anterior segment aqueous drainage device, CPT 
code 65820 would not need to be coded separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of goniotomy services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve goniotomy services (65820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial moderate sedation services (99152) billed for date of 
service December 23, 2021. 
 
You asked the Plan to pay for initial moderate sedation services. You say that you have provided medical 
records to support the service at issue. The Plan denied your request. The Plan says rules for payment have not 
been met because the available medical records do not support the service 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the available documentation 
does not support the presence of an independent trained observer. Based on this information, we decided that 
Medicare rules for coverage of initial moderate sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for initial moderate sedation services (99152) billed for date of service December 
23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance of needle or catheter tip (77003) 
provided on November 16, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says the service at issue is billed with an add-on code which is not being 
billed with an appropriate primary procedure. 
 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 
fluoroscopic guidance is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for fluoroscopic guidance of needle or catheter tip (77003) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210) with an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction. You say that you have been in excruciating pain prior to 
June 2022. The Plan denied your request. The Plan says you are covered for one simple or surgical extraction 
of an erupted tooth per year, only when performed by a participating General Dentist. Consults and dental 
services provided by Oral Surgeons, Periodontists, Endodontists, other dental specialists or non-network 
General Dentists are 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 when performed by an oral surgeon. Therefore, we decided that the Plan does not have to 
pre-approve a tooth extraction (D7210) with an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that you are low risk for this procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee has 
vertebral compression fracture that has not responded to kyphoplasty. Percutaneous vertebral augmentation has 
been requested and approved by the health plan. This is a minimally invasive procedure, and her medical 
records indicate that she is a low risk surgical candidate. There is no documentation that medically necessary 
care associated with this procedure would span a time period of more than 2 midnights. Inpatient admission is 
not medically necessary. Our physician reviewer found that your condition does not meet criteria for coverage 
of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a below knee alignable endoskeletal system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
adjustments to the approved preparatory prosthesis does not constitute the addition of an alignable system. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a medical history of diabetes mellitus type II who underwent a right sided 
transtibial amputation. A prosthetic evaluation indicated that the enrollee is expected to be a K2 level 
ambulator. A new transtibial prosthesis was recommended. The enrollees prosthesis requires an alignable 
system. The requested prosthesis is not a preparatory prosthesis. It requires a test socket for fitting of the 
enrollees residual limb shape for the definitive socket. The alignable system is necessary since the prosthesis 
has movable parts to allow for rotation, height/length adjustment, and linear and angular changes of the 
prosthesis. The parts of the prosthesis must be adjusted for the enrollee to walk properly with it. Therefore, the 
alignable system component can 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a below knee alignable endoskeletal system.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 ,81235, 81292, 81321, 
81301) provided on October 8, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim was not billed 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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206 ,81235, 81292, 81321, 81301) provided on October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on December 15, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 We find that CPT codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. This claim was billed with a place of 
service of 22 (outpatient hospital). These codes require a modifier 26. The claim was not billed with this 
required modifier. 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 the laboratory services 
coded 88341, 88342, 88360, and 88381 provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing coded as 81406, 81405, 81404, 
81403, 81402, and 81401 provided on January 13, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 We find that CPT codes 81406, 81405, 81404, 81403, 81402, and 81401 are not supported in the medical 
record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more 
genes will be considered part of the same panel. A panel constitutes one single procedural service so one code 
should be billed for the panel. Review of the file does not support that only one code was billed for the panel 
provided. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing coded 
as 81406, 81405, 81404, 81403, 81402, and 81401 provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
(D7250) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) provided February 24, 2022, in a specialists office. 
 
You asked the Plan to pay for the removal of residual tooth roots and dental consultation. You say that your 
provider should have gotten prior authorization for the services. The Plan denied your request. The Plan says 
this claim has processed correctly. You paid less than your coinsurance, therefore no payment from the Plan is 
due. 
 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. The Plan covers the removal 
of residual tooth roots and dental consultation with 80% coinsurance when provided by a specialist. 
 
We looked at the file and Medicare rules. You have been asked to pay $436 for the requested services. The 
total cost of the services was $654. The Plans 80% coinsurance for these services is $523.20. This means you 
have been asked to pay less than or equal to the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (cutting 
procedure) (D7250) and consultation - diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310) provided February 24, 2022, in a specialists office.