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

 
We decided that the Plan does not have to pay for the Tdap vaccination you received on June 9, 2022. 
 
You asked the Plan to pay for the Tdap vaccination. You say that your doctor told you that you were due for 
this vaccine, so you said yes.  You believe this preventive health vaccine should be covered. The Plan denied 
your request. The Plan says this vaccination is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap 
vaccination. Therefore, we decided that the Plan does not have to pay for the Tdap vaccination you received on 
June 9, 2022. Benefits for the Tdap vaccination may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 29881) provided to the enrollee on 
January 25, 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 that this denied procedure is inclusive to another code. 
 
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 the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure notes detailed that an arthroscopy was performed, and a posterior horn medial meniscus was noted. 
This was debrided with an oscillating shaver and sharp biter back to smooth and stable edge. There were areas 
of grade 2 and 3 chondrosis about the medial femoral condyle and the patellar articular surface. The 
debridement by arthroscopy was completed, equipment removed, and wound closure was performed. The cyst 
removal was performed in prone position with utilizing a different incision. Therefore, the records do support 
that this surgical knee arthroscopy (CPT 29881) was separate, independent, and distinct from CPT 27345- 
excision of synovial cyst of the popliteal space (Bakers cyst). 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 29881) provided to the enrollee on January 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service March 30, 
2022. 
 You asked the Plan to pay for procedure code 88321. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service March 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2022 to April 22, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service-only code and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2022 to April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 10, 
2022. 
 
You asked the Plan to pay for the services. You say that this claim should be reprocessed. The Plan denied your 
request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 drug testing services provided to the enrollee on 
February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 30, 2022, to 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that when the enrollee was admitted their 
eligibility and benefits were verified and no authorization was required. The Plan denied your request. The Plan 
says the services were provided out-of-network and were not approved in advance. 
  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 home health services provided on March 30, 
2022, to April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical 
First Assistant (CSFA) on June 28, 2021. 
 
You asked the Plan to pay for the CSFA services. You say that this provider was on the only one available to 
provide services. The Plan denied your request. The Plan says this provider is not eligible to bill for these 
services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Certified Surgical First Assistant (CSFA) on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee had no history of atrial 
fibrillation. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an 
ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to 
usual care in reducing stroke or systemic embolism among patients at high risk of stroke but without a known 
prior history of atrial fibrillation. At this time, insertion of an ILR would not be considered medically 
appropriate and necessary in this enrollees clinical 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for laminectomy services provided to the enrollee on January 8, 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 that the denied code remains not supported. 
 
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 the services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
enrollee was being treated for unspecified injury at C5 level of cervical spinal cord and other specified 
spondylopathies, site unspecified. He underwent a laminoplasty with plates at C4-6 and laminectomy at C3 on 
1/8/22.  The procedure notes that the C3 laminectomy was completed first using a combination of high-speed 
drill and Kerrison rongeur laminectomy decompression was performed at C3. In this manner, the lamina at C3 
was removed decompressing the spinal cord widely from the base of C2 to top of C4. After completion at that 
level, the C4-6 laminoplasty was performed, with plate placement. Therefore, the records do support this 
laminectomy as an independent, separate, and disc procedure from the cervical laminoplasty (CPT 63051). 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laminectomy services provided to the enrollee on January 8, 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 power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from April 7, 2021, to April 10, 
2021. 
 
You asked the Plan to pay for the medical services. You say that because the provider is out-of-network, they 
are not limited to any particular time frame. The Plan denied your request. The Plan says [Enter plan denial 
rationale, e.g. "...rules for SNF care have not been met."] 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical services was not filed until April 11, 2022. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
medical services provided from April 7, 2021, to April 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 15, 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 denied codes are not supported by the 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 the denied codes is: 
 
CPT 37184: 
 
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or 
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 
injection(s); initial vessel 
 
CPT 37223: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal stent placement(s), includes angioplasty within the same vessel, when performed (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 the services. Our reviewer says that the services Our 
reviewer found that the documentation does not support coverage of the codes in question. In terms of CPT 
37184 - codes for mechanical thrombectomy, initial vessel -  the operative note does not document that this was 
performed. Angioplasty of the iliac artery is still angioplasty of the artery whether the artery was stenosed or 
occluded. CPT 37184 would not be the appropriate code for this work. Additionally, even if a single stent 
extends from the common iliac artery to the external iliac artery placement of a single stent cannot be billed 
with 2 separate codes. There was one iliac stent to be coded as a single iliac stent code and therefore using 
37223, an add on code signifying a second stent in a different artery would not be appropriate in this setting. 
 
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 surgical services provided to the enrollee on March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services provided on January 
27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
  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 non-emergent ambulance services provided on 
January 27, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 office visit provided on March 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from April 3, 2021, to April 6, 
2021. 
 
You asked the Plan to pay for the medical services. You say that because the provider is out-of-network, they 
are not bound to any time frames. The Plan denied your request. The Plan says you did not timely file this 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical services was not filed until April 11, 2022. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
medical services provided from April 3, 2021, to April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service is separately payable. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 12, 2022.