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

 
We decided that the Plan has to pay for procedure code 64716-RT billed for date of service November 10, 
2021. 
 
You asked the Plan to pay for procedure code 64716-RT. You say that this service should be paid. The Plan 
denied your request. The Plan says that 64716-RT is 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 64716-RT is Neuroplasty (Exploration, Neurolysis or Nerve Decompression) Procedures on the 
Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System. 
 
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 64716-RT. Our reviewer says that this 
service is supported in the medical record. Our reviewer found that the enrollee had a diagnosis of malignant 
neoplasm of thyroid gland with secondary and unspecified malignant neoplasm of intrathoracic lymph nodes. 
The enrollee underwent previous surgery including a right lobectomy and limited central compartment 
dissection in 2020. Significant scar tissue was noted in the central compartment consistent with previous 
thyroid surgery. Bilateral revision central compartment dissection, microdissection of the right recurrent 
laryngeal nerve, and segmental tracheal rings 1-5 were performed.  The operative note documents "Bilateral 
recurrent laryngeal nerves, particularly on the right where there was disease extending within mm's of the 
entrance of the nerve into the cricothyroid joint, were microdissected and mobilized." The documentation 
supports Neuroplasty (Exploration, Neurolysis or Nerve Decompression) Procedures on the Extracranial 
Nerves, Peripheral Nerves, and Autonomic Nervous System in this case. The operative report documents 
exploration and neuroplasty. 
 
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 64716-RT have been met. Therefore, we decided that the Plan 
has to pay for procedure code 64716-RT billed for date of service November 10, 2021.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (CPT code 99284) provided on March 23, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says per the ICD 10 CM Official Guidelines for Coding and Reporting FY 2022 section 13, 
instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. The 
Plan states the claim was billed with T26.92XA Corrosion of left eye and adnexa, part unspecified, initial 
encounter as a primary diagnosis, which is the manifestation, this is not the proper sequencing. The Plan states the claim is not payable as submitted because the underlying condition is required to be first followed by the 
manifestation. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. For proper coding this claim would 
need three diagnosis codes. Therefore, we decided that the Plan does not have to pay for emergency department 
visit for the evaluation and management of a patient (CPT code 99284) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from January 25, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services 
are custodial. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services 
provided from January 25, 2022, to January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the LCD requirement that other 
pathology be ruled out cannot be determined because there is no advanced imaging submitted. Therefore, at 
this time, the request is considered 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional miles on top of the one-way trip mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you need additional mileage to get to your 
appointment. The Plan denied your request. The Plan says the benefit only allows 50 miles per trip. The Plan 
also says that additional mileage beyond 50 miles is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip is within 50 miles driving distance.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 14 additional miles on top of the one-way trip mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-emergent 
and care can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 18, 2022, billed with 
codes 81231, 81328, 81401, 81479, 81355, 81241, 81240, 81291, 81225, 81226, 81227, and 81230. 
 
You asked the Plan to pay for genetic testing. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 
18, 2022, billed with codes 81231, 81328, 81401, 81479, 81355, 81241, 81240, 81291, 81225, 81226, 81227, 
and 81230.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 9, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services are 
only covered when rendered by an in-network provider. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 18, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) radiologic 
examination, foot (73630) injection of drug/substance under skin or into muscle (96372) Prescription drug, 
oral, non-chemotherapeutic, NOS (J8499) provided January 16, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that the physician claim was paid. Please reprocess 
your facility claim as well. The Plan denied your request. The Plan says in order for a facility to receive 
reimbursement for a Medicare member, the facility must be enrolled to participate in the Medicare program 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) 
radiologic examination, foot (73630) injection of drug/substance under skin or into muscle (96372) 
Prescription drug, oral, non-chemotherapeutic, NOS (J8499) provided January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on February 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that you are out-of-network with the Plan 
so authorization was not obtained. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider. The Plan also says the referring provider involved in these services is a non-
participating with the Plan. The Plan also says that they did not authorize any services for the rendering 
provider, the referring provider, or the facility. 
 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 an electrocardiogram (ECG) provided on February 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator trial. 
 
You asked the Plan to pre-approve a sacral nerve stimulator trial. 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 effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 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 sacral nerve stimulator trial. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
meet the coverage criteria detailed in the NCD. Sacral nerve stimulation is not covered for the treatment of 
urinary urge incontinence when related to a neurologic condition. The records show that the enrollee has 
multiple sclerosis. 
 
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 sacral nerve stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacral nerve stimulator trial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) provided to the 
enrollee on November 29, 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 billed initial hospital care at an emergency place of service. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, it should have been billed with an inpatient place of service. 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 initial hospital 
care (procedure code 99223) provided to the enrollee on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for continuity of care with an out-of-network 
provider. 
 You asked the Plan to pre-approve the referral. You say that there are in-network options available. The Plan 
denied your request. The Plan says the enrollee has been seeing this provider within the last two months. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found that there is no 
clearly stated reason for why the enrollee needs to continue with an out-of-network provider. All of the services 
and medications ordered are routine. The request to continue with an out of network provider is 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for continuity of care with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84630, 36415, 84597, 84590) provided 
on March 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 laboratory services (84630, 36415, 84597, 84590) 
provided on March 17, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
are non-emergent and care can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are ambulating household distances. Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 
Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
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 pre-approve skilled nursing facility (SNF) care.