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

 
We decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95937) provided 
on August 30, 2022. 
 
You asked the Plan to pay for the neuromonitoring services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services 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 code 95886, 95907, & 95937 is not supported in the medical record. Specifically, code 
95937 is not supported. The record states that this code was reported for train of four testing. According to 
AMA CPT Assistant, Volume 26, Issue 2, train of four is bundled with intraoperative neuromonitoring of EMG 
and is not separately reportable. Code 95907 is not supported by the medical record. The record states that free-
running, bilateral lower EMG responses were recorded from needle electrodes in the muscles. According to 
AMA CPT Assistant, June 2005 page 9, free-running and triggered EMG studies performed for intraoperative 
monitoring is reported with a more appropriate code.  Code 95886 is an add-on code reported without an appropriate primary code. Based on this information, we 
decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we 
decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95937) provided on 
August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria treatments. 
 
You asked the Plan to pre-approve the Simponi Aria. You say that it is felt that the preferred drugs cannot be 
used as they require methotrexate which the enrollee cannot take. The Plan denied your request. The Plan says 
there is no reason that the preferred drugs cannot be used. 
 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 the Simponi Aria. Our reviewer says 
that the requested drug is not considered reasonable and necessary. Our physician reviewer found based on the 
medical records provided there is no indication that the enrollee has tried and failed the required drugs Inflectra 
or Renflexis. There is no indication that the plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. The prescriber argues that Inflectra and Renflexis require co-treatment 
with methotrexate (which the patient cannot tolerate). The Medicare-approved major compendia do not support 
this assertion. 
 
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 Simponi Aria have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Simponi Aria treatments.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on June 23, 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 Current Procedural Terminology (CPT) code 95822-26 remains not supported. 
 
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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 records states that the EEG 
was performed for monitoring during a spinal/non-intracranial procedure. According to CPT guidelines and 
descriptions, there is a more specific code for this service. 
 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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on June 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that this therapy helps you. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug services billed with code J3490 for 
October 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 20526. Payment for code J3490 is included in the global surgical package for 20526. 
Therefore, we decided that the Plan does not have to pay for the unclassified drug services billed with code 
J3490 for October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested seat elevation 
system is medically necessary. The Plan denied your request. The Plan says the seat elevation system is a non-
covered accessory because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower grab bar (E0241). 
 
You asked the Plan to pre-approve a grab bar. You say that you live by yourself and have already fallen twice 
in the tub. You need the grab bars when you are showering. The Plan denied your request. The Plan says the 
requested grab bar is not a covered benefit under your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a shower grab bar (E0241).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7323 billed for date of service December 7, 
2021. 
 You asked the Plan to pay for procedure code J7323. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 J7323 is 2. The MAI value for this code is 3. You billed 3 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 J7323 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code J7323 billed for date of service December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires 24-hour assistance 
for all safe mobility, and significant assistance with their care. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee can get the services they need provided in 
another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care setting. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for ultraviolet light therapy provided on February 4, 2022, 
to February 19, 2022. 
 
You asked the Plan to pay more for the therapy services. You say that that you received the treatment for your 
health and the Plan did not tell you that you were not approved. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You have been asked to pay the difference between the billed amount and allowed amount for the ultraviolet 
therapy. The Plan is not obligated to pay more than the allowed amount for the service at issue. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay more for ultraviolet light therapy provided on February 4, 2022, to February 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided March 
24, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim to be 
reconsidered for payment for medical necessity, as pneumatic compression devices are a proven treatment for 
deep venous thrombosis. The Plan denied your request. The Plan says pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service February 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that these should be paid 
without a modifier. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
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) 88341, 88342, 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) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the criteria for approval have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 2 very heavy 
duty, patient weight capacity 451 to 600 pounds (K0808). 
 
You asked the Plan to pre-approve a heavy-duty POV. You say that you do not understand why the scooter is 
denied. The Plan denied your request. The Plan says you must meet the above criteria to be approved for a 
POV. The POV is being denied because your home is not accessible to a POV. You have declined installation 
of the recommended modular ramp. To be approved for a POV your home must have safe access for use of the 
POV. 
 
The Plan follows Medicare rules. Medicare rules say that a POV is covered if all of the basic coverage criteria 
is met.  
 
The file shows that you have three steps to enter and exit your home. You had an evaluation by a physical 
therapist who recommended a POV and a ramp. You had an assessment for a ramp but declined installation of 
the ramp. You requested a portable ramp but there is no evidence that a portable ramp would provide safe 
access. To be approved for a POV, your home must have safe access for use of the POV. This means that 
Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV), group 2 very heavy duty, patient weight capacity 451 to 600 
pounds (K0808).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the food thickeners billed with code B4100 for June 13, 
2022. 
 
You asked the Plan to pay for these services. You say that the enrollee has underlying medical conditions that 
require the services. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that food thickeners (B4100) are denied as non-covered. 
 
We looked at the file and Medicare rules. The services at issue are food thickeners billed with code B4100. 
These services are denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to 
pay for the food thickeners billed with code B4100 for June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on August 5, 2022. 
 
You asked the Plan to pay for the hospital care. You say that you obtained outpatient prior authorization for 
this procedure (CPT codes 11440, 38500 and 78195), however during the surgery, it was determined that the 
enrollee required additional procedures based on intraoperative findings. The Plan denied your request. The 
Plan says prior authorization is required for in-network inpatient hospital care 
 
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 find that the inpatient care is not supported in the medical record. Specifically, the records 
show that the Plan had authorized the services as an outpatient procedure. The records show that the Plan 
requested from the provider a corrected claim for the outpatient care and was informed that a corrected claim 
will not be submitted at this time. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital care provided on August 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services billed with code 99291 for May 15, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include a 
critical care progress note for the billed date of service. 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 
pay for the critical care services billed with code 99291 for May 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on August 15, 
2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this code cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that  Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service is not eligible for coverage when billed by an individual 
provider. This service is covered when billed by hospitals, CAH's, and free-standing opioid treatment facilities. 
Based on this information, we decided that Medicare rules for coverage of the opioid treatment services have 
not been met. Therefore, we decided that the Plan does not have to pay for opioid treatment services (G2067) 
provided on August 15, 2022.