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

 
We decided that the Plan does not have to pay for procedure code(s) 88342-59, 88307, 88331, and 88360 billed 
for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code(s) 88342-59, 88307, 88331, and 88360. You say that you have 
provided documentation to support payment. The Plan denied your request. The Plan says these codes are included in the facility payment and is not separately payable. You did not bill with the appropriate modifier to 
have these codes paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88342-59, 88307, 
88331, and 88360. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88342-59, 88307, 88331, and 88360. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88342-59, 88307, 88331, and 88360 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88342-59, 88307, 88331, and 88360 billed for date of service June 
2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36215 and 75710 rendered on September 
20, 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 in 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 36215: 
 
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 
vascular family 
 
CPT 75710: 
 Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that the services in question were rendered.  Code 36215 and 75710 code are designed to code for 
selective catheterization of a brachial cephalic artery and diagnostic extremity angiography respectively. 
Imaging the artery in the general region of the arteriovenous (AV) access is a component of a complete 
fistulogram and not separately reportable. Selective access of the artery is generally not required for this 
information and the documentation does not describe extenuating circumstances. Additionally, coding for 
diagnostic angiography requires a full description of a unilateral extremity angiogram to justify billing for code 
75710.  This was not provided. 
 
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 procedure codes 36215 and 75710 rendered on September 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drug bevacizumab before they will approve the requested drug. The enrollee has not 
tried and failed the required drug. The documentation does not support that bevacizumab would likely be less 
effective and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Eylea (J0178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the gingival irrigation-per quadrant 
(D4921 x 4), limited oral evaluation-problem focused (D0140), the extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210), the upper partial denture (D5225), and the lower partial 
denture (D5226) provided on September 28, 2022 and October 17, 2022. 
 
You asked the Plan to issue additional payment for these dental items/services. You say that you are requesting 
a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the items/services provided 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. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the items/services provided was exhausted on date of service October 17, 2022. 
Specifically, the annual maximum dental benefit is $1,000 per year. The Plan issued payment to the provider in 
the amount of $1,000 for dental items/services provided in the 2022 calendar year. Therefore, you have 
exhausted the allowable benefit for these items/services. Additionally, gingival irrigation-per quadrant is not a 
covered benefit. Therefore, we decided that the Plan does not have to issue additional payment for the gingival 
irrigation-per quadrant (D4921 x 4), limited oral evaluation-problem focused (D0140), the extraction, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), the upper partial denture (D5225), 
and the lower partial denture (D5226) provided on September 28, 2022 and October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from November 27, 
2021, to December 22, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that medical 
records were sent for review. The Plan denied your request. The Plan says the provider has reported inpatient 
hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code E43. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee presented with nausea and vomiting. The workup revealed anastomotic 
stenosis of gastrojejunostomy and underwent conversion to Roux-en-Y gastrojejunostomy. However, although 
some degree of malnutrition was evidenced, severe protein-calorie malnutrition was not clearly supported in 
the provided documentation. There was a reported 8.5% weight loss over 2 months. Moderate muscle wasting 
was noted, not severe, and body mass index (BMI) was 20.85. This would describe a moderate protein-calorie 
nutrition status not severe. Therefore, this coding for severe protein-caloire malnutrition (E43) is not 
supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from November 27, 2021, to December 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971-26-XS billed for date of service June 
19, 2022. 
 You asked the Plan to pay for procedure code 93971-26-XS. You say that the claim was billed correctly and 
should be paid. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93971-26-XS is 1. The MAI value for this code is 3. You billed 2 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93971-26-XS have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93971-26-XS billed for date of service June 19, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
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 the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has psoriasis vulgaris. 
She has not tried and failed the Plan's required drugs, Inflectra or Avsola. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Ilumya is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on December 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that please review the attached medical records and 
process the claim towards payment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99215) provided on 
December 12, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305-59, 88342-59, 88112, and 88341-
59 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305-59, 88342-59, 88112, and 88341-59. You say that you 
have provided documentation to support payment. The Plan denied your request. The Plan says these codes are included in the facility payment and is not separately payable. You did not bill with an appropriate modifier to 
allow for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305-59, 88342-59, 
88112, and 88341-59. This means there is both a professional and technical component for the CPT code(s). In 
this case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88305-59, 88342-59, 88112, and 88341-59. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88305-59, 88342-59, 88112, and 88341-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305-59, 88342-59, 88112, and 88341-59 
billed for date of service May 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 93041 provided on October 8, 2022. 
 
You asked the Plan to pay for codes 93005 and 93041. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 93005 and 93041 are not supported in the medical record. Specifically, these codes 
were billed with code 99285 on the same claim, with the same date of service, with a revenue code of 450. This 
gives code 99285 a status indicator of "V".  Procedure codes 93005 and 93041, which have a status indicator of Q1, are not separately payable. Based on 
this information, we decided that Medicare rules for coverage of codes 93005 and 93041 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 93005 and 93041 provided on October 8, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this code was denied improperly and it is 
separately payable. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93042 billed for date of service September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided July 5, 2021. 
 
You asked the Plan to pay for the wearable automatic external defibrillator. You say that you are asking for 
extending of the timely filing limit as the transition in the authorization process delayed this claim. The Plan 
denied your request. The Plan says the claim was filed past the timely filing limitation. 
 
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 wearable automatic external defibrillator was not filed until November 7, 
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 the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided July 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided October 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that please reprocess these 
transcutaneous electrical nerve stimulation (TENS) supplies (A4595) as per the clinical policy bulletin for electrical stimulation for pain medical necessity has been met The Plan denied your request. The Plan says the 
service is considered experimental or investigational. 
 
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 pay for the electrical stimulator supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided medical records and the peer reviewed medical literature do 
not document that use of transcutaneous electrical nerve stimulation has been shown in controlled studies to 
result in long term health benefits in patients with chronic, recurrent neck pain, cervicalgia and cervical disc 
degeneration. As summarized in Up to Date: "Although transcutaneous electrical nerve stimulation (TENS) is 
widely used in the management of musculoskeletal pain syndromes, the evidence of its efficacy is uncertain. In 
a systematic review including seven trials of TENS in the treatment of chronic neck pain, no definitive 
conclusions could be drawn due to the heterogeneity in study interventions and measured outcomes. Even 
when including only the two trials comparing TENS with placebo (sham TENS treatment) for neck pain, there 
was very low certainty evidence for similar short-term pain outcomes. There is no documentation that the 
TENS unit/supplies at issue in this case meet all Medicare criteria for medically reasonable and necessary for 
the patient. 
 
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 electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 
(A4595) provided October 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Genotropin Miniquick injection. 
 
You asked the Plan to pre-approve Genotropin Miniquick. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Genotropin 
Miniquick injection.  
 Benefits for Genotropin Miniquick 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: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy (EGD) (procedure code 
43235) rendered on September 1, 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 service is not supported without the required documentation. 
 
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 
records show that the EGD is the approach to the endoscopic retrograde cholangiopancreatography (ERCP), 
and not separate diagnostic procedure. The use of modifier 59 is not substantiated. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for esophagogastroduodenoscopy (EGD) (procedure code 43235) rendered on September 1, 2022.