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

 
We decided that the Plan has to pay for genetic lab testing services provided on June 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that your primary care doctor ordered this test for you, 
so you believe it was approved. The Plan denied your request. The Plan says that this testing was not approved 
because no medical records were provided to show the medical necessity of the testing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
According to your appeal request, your primary care doctor ordered this test for you.  The Plan has failed to 
provide information in the file regarding the contract status of your primary care provider, so we can only 
assume they are a contract provider with the Plan.  In addition, in the file sent to us, the Plan stated that the lab 
from whom you received the services in question is a contract provider as well. You were referred for the lab 
services by a contract provider and provided these services by a contract provider. The file does not show that 
the Plan provided notice that the lab services would not be covered prior to you receiving them. Under 
Medicare rules, this means the lab services are considered approved by the Plan. Therefore, we decided that the 
Plan has to pay for genetic lab testing services provided on June 25, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soma. 
 
You asked the Plan to pre-approve Soma. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Soma.  
 
Benefits for Soma 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit you provided on October 6, 2021. You are an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You did not provide an argument with your appeal request. 
The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
You are not a network provider with the Plan. 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 you provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Insertion of drug-eluting implant (0356T) provided on 
August 10, 2021. 
 
You asked the Plan to pay for code 0356T. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met.  
We looked at the file and Medicare rules. In this case, there were no medical records provided for review to 
determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the 
Insertion of drug-eluting implant (0356T) provided on August 10, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the shoulder arthroscopy (29822) provided on May 26, 2021. 
 
You asked the Plan to pay for the shoulder arthroscopy (29822). You say that coding edits allows payment on 
this line when billed with an applicable modifier. You say that the attached documentation should be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says that CPT code 29822 is considered 
inclusive to CPT code 29827. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records to 
support the denial. The Plan has not forwarded any clinical information and we are unable to determine if the 
Plan was justified in denying the billed services. It is the burden of the Health Plan to substantiate their denial 
with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for the shoulder arthroscopy (29822) provided on May 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thromboendarterectomy (35306) provided on November 
22, 2021. 
 
You asked the Plan to pay for the thromboendarterectomy (35306). You say that the claim should be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure codes 35303, 35304 and 
35305 were approved. The Plan also says that CPT code 35306 remains denied as the service 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 35306 is thromboendarterectomy, including patch graft, 
if performed; each additional tibial or peroneal artery (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 thromboendarterectomy (35306). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the operative report does not include additional tibial or peroneal artery thromboendarterectomy 
performed. 
 
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 thromboendarterectomy (35306) have not been met. Therefore, we decided 
that the Plan does not have to pay for the thromboendarterectomy (35306) provided on November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy (29826) provided on November 12, 
2021. 
 
You asked the Plan to pay for the shoulder arthroscopy (29826). You say that the operative note clearly 
dictated that after the bursectomy was done the subacromial decompression described by CPT code 29826 was 
done then the clavicle excision. You say that modifier 59 was used correctly as this was a separately 
identifiable procedure and CPT code 29826 should be paid. The Plan denied your request. The Plan says 
procedure code 29826-59 is considered inclusive to CPT code 23412. 
 
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 29826 is a column II code to column I code 23412; however, 29826 
was billed with a modifier.  
 
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 shoulder arthroscopy (29826). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
Medicare considers the shoulder to be a single structure. Therefore, CPT 29826 is a component of CPT 23412 
and cannot be reported when performed on the same shoulder, same session. A modifier would not appended to 
bypass the edit. 
 
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 shoulder arthroscopy (29826) have not been met. Therefore, we decided that 
the Plan does not have to pay for the shoulder arthroscopy (29826) provided on November 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve Trulance. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.  
 
Benefits for Trulance 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would like a specific type of 
radiation only available at this provider. The Plan denied your request. The Plan says the services are available 
from network providers. 
 
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. The Plan confirmed that the network 
providers are able to provide stereotactic body radiation therapy (SBRT) for the enrollee. 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 a referral to an out-of-network radiation oncologist.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 19, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95724 billed for date of service October 12, 
2021. 
 
You asked the Plan to pay for procedure code 95724. You say that you have provided medical records to 
support payment for this service. The Plan denied your request. The Plan says it is not the member's primary 
insurer.  The Plan says that you must submit your claim first to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has advised you 
on multiple occasions that the member has a primary insurer, and you have a copy of the primary insurance 
card. As the secondary insurer, the Plan cannot be held responsible for procedure code 95724 until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for 
procedure code 95724 billed for date of service October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy (29823) provided on October 28, 
2021. 
 
You asked the Plan to pay for the shoulder arthroscopy (29823). You say that CMS made three exceptions 
related to separate reporting of debridement including if extensive debridement is performed in a different area 
of the same shoulder if one arthroscopic shoulder procedure is performed. You say that medical necessity is 
established by the documentation and the denial should be reversed with subsequent payment. The Plan denied 
your request. The Plan says procedure code 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
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 shoulder arthroscopy (29823). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the CPT code description states 3 or more discrete structures. In this case, the operative report does not include 
sufficient documentation to confirm 3 or more discrete structures per CPT code description to verify extensive 
debridement. 
 
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 shoulder arthroscopy (29823) have not been met. Therefore, we decided that 
the Plan does not have to pay for the shoulder arthroscopy (29823) provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for supply allowance for therapeutic CGM, includes all supplies and 
accessories, 1 month supply = 1 unit of service (CPT code K0553) provided on March 28, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the documentation submitted did not include valid Proof of Delivery [or] a Delivery 
Ticket to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
 
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 CGM supplies have been met. A delivery ticket with all of the 
required criteria was submitted. Therefore, we decided that the Plan has to pay for supply allowance for 
therapeutic CGM, includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) 
provided on March 28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the synovectomy (29821) and arthroscopic subacromial 
decompression (29826) provided on June 10, 2021. 
 
You asked the Plan to pay for the synovectomy (29821) and arthroscopic subacromial decompression (29826). 
You say that the arthroscopic subacromial decompression was medically necessary and the synovectomy was 
not done simply for visualization purposes. You say that the operative report is enclosed, and payment should 
be reconsidered. The Plan denied your request. The Plan says procedure code 29823 has been approved. The 
Plan also says that procedure code 29821 is considered inclusive to procedure code 29823 and procedure code 
29826 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 29821 is arthroscopy, shoulder, surgical; synovectomy, 
complete. The CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of 
subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, 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 synovectomy (29821) and arthroscopic subacromial 
decompression (29826). Our reviewer says that the documentation submitted was reviewed and does not meet 
the criteria for coverage. Our reviewer found that the operative report does not support an underlying diagnosis 
of pathologic synovium. CPT code 29821 should only be used when the underlying diagnosis is pathologic 
synovium such as found in rheumatoid arthritis or pigmented villonodular synovitis. In addition, the operative 
report does not include sufficient documentation to confirm all criteria in the CPT code description of 29826 
has been met. In this case, the documentation does not support a partial acromioplasty was performed, and 
therefore 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 the synovectomy (29821) and arthroscopic subacromial decompression (29826) 
have not been met. Therefore, we decided that the Plan does not have to pay for the synovectomy (29821) and 
arthroscopic subacromial decompression (29826) provided on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bunionectomy with sesamoidectomy (28298) provided on 
November 24, 2020. 
 
You asked the Plan to pay for the bunionectomy with sesamoidectomy (28298). You say that XA was removed 
from procedure code 28298 and 28308. You say that procedure code 28298 should be reviewed for possible 
reimbursement. The Plan denied your request. The Plan says procedure codes 28297, 28285 and 28308 were 
approved. The Plan also says that CPT code 28298 is inclusive to procedure code 28297. 
 
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 28298 
is a column II code to column I code 28297. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the bunionectomy with sesamoidectomy (28298) provided on 
November 24, 2020.