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

 
We decided that the Plan does not have to pay for nail debridement (11721) provided on April 5, 2022. 
 
You asked the Plan to pay for nail debridement (11721). You say that the medical records support the service 
billed. You say that the claim should be reviewed and reprocessed. The Plan denied your request. The Plan says 
the documentation does not clearly indicate the nail debridement was performed at a separate site. 
  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 11721 is a column II code to column I code 11055; however, 11721 
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 nail debridement (11721). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report does not include enough detail to confirm the nail debridement was a separate procedure 
from the lesion paring/cutting procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nail debridement (11721) have not been met. Therefore, we decided that the 
Plan does not have to pay for nail debridement (11721) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 31. 
 
You asked the Plan to pre-approve the dental service. You say that the crown has been approved. You say that 
the amount of decay present under the old crown will require removal of more tooth structure. You also say 
that the core build up is necessary for the crown retention. The Plan denied your request. The Plan says your 
benefit for the requested core build up for tooth # 31 has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested core build up for tooth # 31 was exhausted on date of service January 3, 
2019. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #8 (D2751). 
 
You asked the Plan to pre-approve a crown. You say that the dental work needs to be finished. The Plan denied 
your request. The Plan says there is no evidence of tooth decay or missing crown to support the need for a 
replacement. 
 
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 a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the provided x-rays do not show any 
clear defects or decay that would make the existing crown non-serviceable.  If the existing restoration does not 
have a noted defect, there is no medical necessity to replace the existing crown. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #8 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions of tooth #'s 4, 5, 8, 9, 10, 16, 21, 22, 23, 24, 
25, 28, and 29. 
 
You asked the Plan to pre-approve extractions of tooth #'s 4, 5, 8, 9, 10, 16, 21, 22, 23, 24, 25, 28, and 29. You 
say that you have a hard time eating so you really need dentures. The Plan denied your request. The Plan says 
they approved extraction of tooth #'s 2 and 13, therefore the benefit has been exhausted. 
 
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. Supplemental dental services 
benefit includes non-surgical or surgical extractions (pulling of teeth) (2 procedure codes per calendar year). 
 
We looked at the file, the Plans rules, and Medicares rules. The plan approved two extractions for tooth #s 2 
and 13. Therefore your benefit has been exhausted for the 2022 plan year. Therefore, we decided that the Plans 
rules for coverage of extractions of tooth #'s 4, 5, 8, 9, 10, 16, 21, 22, 23, 24, 25, 28, and 29 have not been met.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on December 28, 
2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you went to the hospital and 
were not treated at home. The Plan denied your request. The Plan says non-transport ambulance services are 
not covered. The Plan says that you had two ambulance services on this date.  For the first one (this one in 
question), you had low blood sugar and you had become more alert by the time the ambulance arrived.  You 
refused transport at that time.  For the second ambulance service, you were transported to the hospital later in 
the day.  That claim has been paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 28, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services provided on 
December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lodging related to a surgical followup in Spain. 
 
You asked the Plan to pay for the lodging services. You say that you feel this must be covered because you had 
to return to Spain to be seen by your surgeon. The Plan denied your request. The Plan says the Plan is only 
required to cover lodging for transplants. 
 
The Plan must follow Medicare rules. Medicare rules say that care provided outside of the United States is 
generally not covered. Your Plan offers coverage for only emergency or urgently needed services. 
 
Though you state that this was an urgent need, urgently needed means an unforeseen need. You left the country 
in order to receive scheduled care. This is not considered urgent per your contract. Therefore, we decided that 
the Plan does not have to pay for the lodging related to a surgical followup in Spain.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on January 4, 2022. 
 
You asked the Plan to pay for the ER visit. The Plan denied your request. The Plan says Medicare does not 
allow for payment to non-Medicare providers. 
 
The Plan must follow Medicare rules. Medicare rules say that current law does not recognize Independent 
Freestanding Emergency Departments as a certified Medicare provider, meaning they cannot bill Medicare and 
Medicaid for services. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER visit have not been met. Specifically, a freestanding emergency department is not eligible 
for reimbursement. Therefore, we decided that the Plan does not have to pay for the ER visit provided on 
January 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on April 10, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you did not make the 
decision to not be transported. The Plan denied your request. The Plan says non-transport ambulance services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 10, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services provided on 
April 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on May 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
appropriate and should be paid. The Plan denied your request. The Plan says that this claim is a duplicate. 
 
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 Plan's sole rationale for denial is that this claim is a duplicate.  
However, in its case file submission to us, the Plan has failed to provide any evidence showing that this is a 
duplicate claim or that it has previously processed another claim for this date of service.  The burden is on the 
Plan to support its denial.  By failing to include this documentation in the case file, the Plan has not met this 
burden. Therefore, we decided that the Plan has to pay for lab services provided on May 5, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81185, 81401, 81403, 81404, 81405, 
81406 and 81479) billed for date of service January 6, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were ordered by a physician and 
were reported correctly. The Plan denied your request. The Plan says no medical records were provided to 
support these services as billed appropriately and/or medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. Specifically, no medical records were provided to show that these services were medically necessary and were 
reported correctly. Therefore, we decided that the Plan does not have to pay for laboratory services (81185, 
81401, 81403, 81404, 81405, 81406 and 81479) billed for date of service January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met. Our physician 
reviewer found the enrollee has right shoulder pain from osteoarthritis. A right total arthroplasty is planned. 
The provided documentation does not reveal an unstable condition or high risk factor that would expect the 
enrollee to require hospital services to likely cross two midnights following the arthroplasty procedure. The 
inpatient level of care is therefore not reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing billed with procedure code 81455 for date 
of service March 2, 2022. 
 
You asked the Plan to pay for procedure code 81455. You say that these services were reasonable and 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this testing was 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient. 
 
We looked at the file and Medicare rules. At the time of services, CPT code 81455 was listed under the Group 
3 Paragraph of Article A56199. This means that at the time of services, code 81455 was considered 
automatically denied as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81455 have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory testing billed with procedure code 81455 for date of service March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19370-78 billed for date of service February 
23, 2022. 
 
You asked the Plan to pay for procedure code 19370-78. You say that this code is supported in the medical 
records. The Plan denied your request. The Plan says code 19370-78 is not supported in the medical records. 
 
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 19370 is Revision of peri-implant capsule, breast, 
including capsulotomy, capsulorrhaphy, and/or partial capsulectomy. 
 
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 19370-78. Our reviewer says that the medical 
records do not support payment of 19370-78. Our reviewer found the operative report does not include 
documentation of peri-implant capsule revision, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy. The operative report documents Upon entering of the periprosthetic immature capsule, large 
amount of dark fluid was encountered. The fluid was evacuated and the implant removed...Hydrogen peroxide 
was actually utilized to remove the attached clots so as not to incite any fresh bleeding by abrasive action"  Per 
NCCI Policy, " The physician revises a peri-implant capsule of the breast by making an incision in the skin of 
the breast, at the site of a mastectomy scar, in the skin fold beneath the breast, or around the nipple. In a 
capsulotomy, the physician uses a cautery knife to cut into the area of fibrous scarring associated with a breast 
implant. Incisions are made into the scar (contracted capsule) to cut around its circumference and enlarge the 
pocket in which the implant is placed. Loosening the capsule relieves pain and tightness caused by the 
contracture. No tissue is removed. The incision is repaired with layered closure. A capsulorrhaphy reshapes or 
recontours the capsule while tightening and repositioning the capsule pocket so that the capsule fits back within 
the sutures surrounding the implant, while the capsulectomy described by this code removes a portion of the 
capsule". This procedure cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 19370-78 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 19370-78 billed for date of service February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37223-RT billed for date of service February 
28, 2022. 
 
You asked the Plan to pay for procedure code 37223-RT. You say that this service was an integral part of the 
procedure performed and should be paid. The Plan denied your request. The Plan says code 37233-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 37223-RT is Revascularization, endovascular open or 
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes 
angioplastry 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 procedure code 37223-RT. Our reviewer says that this code 
is not supported in the medical record. Our reviewer found the operative report does not include documentation 
of revascular iliac artery, each additional ipsilateral iliace vessel with transluminal stent placment. The 
operative report documents:  "The lower aorta, common iliac artery, external iliac artery, common femoral 
artery, popliteal artery, and anterior tibial artery were imaged. The lower aortic and right common remoral iliac 
artery stent was completely thrombosed and occluded." The operative report does not describe access is gained 
using a small open incision or a percutaneous sheath. Typically, a femoral approach under local anesthesia is 
used. After sheath placement, intra-arterial heparin is administered. Using a retrograde approach and under 
angiographic guidance, the occlusion is crossed using a catheter and guidewire. The balloon catheter is inflated 
in order to dilate the vessel to a larger diameter.  Following dilation and stent deployment, an angiogram is 
performed to assure appropriate placement and to evaluate the final result. Report 37223 for each additional 
ipsilateral vessel into which a stent is placed. This procedure cannot be verified in the operative report. 
 
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 37223-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 37223-RT billed for date of service February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care provided on February 11, 2022. 
 
You asked the Plan to pay for the initial hospital care. You say that providers in the same group practice but 
different specialties may bill and be paid. You say that the records should be reviewed, and the claim 
reprocessed. The Plan denied your request. The Plan says the claim reprocessed to deny under hospice 
coverage and Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular genetic testing provided 
on September 29, 2021 billed with codes 81286, 81400, 81413, 81414, 81442 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical records. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare billing guidelines and/or do not meet Medicare criteria for coverage. 
 
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 the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular genetic testing provided on September 29, 2021 billed with codes 81286, 81400, 81413, 81414, 
81442 and 81479.