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

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00813) provided to the 
enrollee on May 7, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there were no medical records provided to support an additional claim/procedure. 
 
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 00813 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum." 
 
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 there is evidence of the surgical 
operative notes in the medical records.  However, no intra-procedural or intraoperative anesthesiology records 
were submitted for either CPT code billed. One page of the anesthesia record documents patient demographics 
and summary of CPT code 00813-QZ-59: Anesthesia for combined upper and lower gastrointestinal 
endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum (55 units billed on 
remittance sheet), performed under monitored anesthesia care (MAC) on 5/7/2021 (anesthesia time: 1244-
1339). 
 However, there were no anesthesiology records submitted for any time period.  This claim apparently bundled 
with an additional claim of CPT 00840-QZ: Anesthesia for procedures on the lower abdomen (210 units 
billed).  Again, no intraoperative anesthesiology records were provided for this additional claim/surgical 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 00813) provided to the enrollee on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that after two surgeries, you cannot walk. The Plan 
denied your request. The Plan says the documentation shows conflicting information on your mobility. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation is 
conflicting on whether you have a gait abnormality that impairs MRADLs in the home. The 
submitted  progress notes have conflicting information and include that you are ambulating normally.  
 The documentation indicates that you are being referred to physical therapy to see what equipment you need in 
the home for activities of daily living. Given this conflicting information, it is not clear if your mobility deficit 
is unable to alleviated by a walker or manual wheelchair. There is no detailed upper extremity musculoskeletal 
examination indicating why a manual wheelchair  or properly configured walker cannot be used.  The 
documentation is not consistent that the requested scooter will significantly improve MRADL performance in 
the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided August 31, 2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you received a denial of payment. You 
went to your doctor and got a referral to this chiropractor. You asked if the chiropractor is covered. You paid 
$10 at the visit and then received a bill for $25. The Plan denied your request. The Plan says this service is not 
covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for an out of network procedure (66984 (LT, RT) 
Extracapsular cataract removal with insertion of intraocular lens prosthesis) at the in-network rate. 
 
You asked the Plan to provide coverage for these services at the in-network rate. The Plan denied your request. 
The Plan says because these services are covered in-network, while you can have them done out of network, 
the contract does not require a reduction to the in-network rate. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that your cost share will be 
higher when you use out of network providers. The Plan is only required to provide coverage for out of 
network services at the in-network rate when you have exhausted all options in network and the service is truly 
only overed out of the contract coverage area. The records do not show you have exhausted all in-network 
providers who can render this service.  Therefore, we decided that the Plan does not have to provide coverage for an out of network procedure (66984 
(LT, RT) Extracapsular cataract removal with insertion of intraocular lens prosthesis) at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of benign lesion (11403) billed for date of 
service August 16, 2021. 
 
You asked the Plan to pay for an excision of benign lesion. You say that you have provided records to support 
the code billed. The Plan denied your request. The Plan says records do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 11403 is "Excision, benign lesion including margins, 
except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm." 
 
 
 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 an excision of benign lesion. Our reviewer says that the CPT 
code at issue does not meet criteria for reimbursement. Our reviewer found that the record indicates that the 
enrollee underwent a procedure. The provided operative record and the pathology report do not support the 
dimensions of the code billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an excision of benign lesion have not been met. Therefore, we decided that the 
Plan does not have to pay for an excision of benign lesion (11403) billed for date of service August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), needle 
electromyography (95885) and nerve conduction studies (95911) provided on January 12, 2021. 
 
You asked the Plan to pay for the EEG, needle electromyography and nerve conduction studies. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the documentation submitted 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 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 EEG, needle electromyography and nerve conduction 
studies. Our reviewer says that CPT code 95955 does not meet criteria for billing or reimbursement 
consideration.  Per CPT manual, this procedure code is a "Special EEG Tests".  Technical report does not 
include documentation of an additional testing, as well as, any additional testing would be inclusive to the 
primary neuromonitoring procedure code.  CPT code 95885 does not meet criteria for billing or reimbursement consideration. This procedure is done with nerve conduction tests.  In this case nerve conduction tests cannot 
be verified in documentation submitted, and therefore this procedure would not be covered. Our reviewer found 
CPT code 95911 does not meet criteria for billing or reimbursement consideration. Technical report describes 
Pedicle screw stimulation which should not be reported for nerve conduction studies.  Which consists of 
electrodes placed on the area to be tested, to measure amplitude and latency/velocity study.  Therefore 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 the EEG, needle electromyography and nerve conduction studies have not been 
met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), 
needle electromyography (95885) and nerve conduction studies (95911) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal injection treatment (CPT code(s): 64636 and 
64635). 
 
You asked the Plan to pre-approve the services. You say that you need the outpatient procedure due to nerve 
pains in back and have had two (2) of the same procedure done prior by a different doctor. You state you are 
unable to get back surgery because you are too at risk to be put under general anesthesia. You state you are 
always in pain, and you have fallen and were in a really bad car accident. You state the procedures are the only 
thing that subside the pain. The Plan denied your request. The Plan says your request is not medically 
necessary because your records show that you did not receive at least 80% relief of your pain from diagnostic 
blocks. 
 
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 services. Our physician reviewer found according to the coverage criteria, an initial thermal RFA of cervical, thoracic, or lumbar paravertebral 
facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had 
at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent 
minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the 
agent used). In this case, the documentation indicates that the two test blocks performed provided greater than 
50% reduction of pain but not the required minimum of 80% relief of pain. The review has determined that the 
medical records provided do not meet the coverage requirements listed in the LCD. 
 
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 pre-approve the spinal injection treatment (CPT code(s): 64636 and 64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an oncology office visit provided on 
September 24, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that the provider did not really do 
anything for you, so you should not have to pay a copayment. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for specialist visit.  
 
You have been asked to pay the allowed amount of $22.18, which is less than the $35 copayment for specialist 
visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. 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 waive the copayment for an oncology office visit provided on September 
24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 20, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had on August 6, 2021. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were under the assumption that this 
visit would be covered. The Plan denied your request. The Plan says you already exhausted your annual 
wellness visit benefit on January 29, 2021. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on August 6, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venography (75822) provided on October 8, 2021. 
 
You asked the Plan to pay for the venography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 37238 and 
75822. 
 
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 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 venography. Our reviewer says that CPT code 75822 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does 
not support CPT 75822 as a separate procedure from CPT 37238 Transcatheter placement of an intravascular 
stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty 
within the same vessel, when performed; initial vein.  Procedure report describes a venography followed by 
treatment of the same vessel.  Therefore, CPT 75822 would not be reported separately, as CPT 37238 includes 
radiological supervision and interpretation. 
 
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 venography have not been met. Therefore, we decided that the Plan does not 
have to pay for venography (75822) provided on October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT) code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of spondylosis have not been demonstrated in the peer-reviewed literature. The Plan states more research is 
needed to show safety and efficacy of the procedure. 
 
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 pre-approve the intracept 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested intracept intraosseous nerve ablation system 
at L4-L5, in this case, is not medically reasonable or necessary. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intracept 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept 
procedure (CPT) code 64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benztropine tablets for the enrollee. 
 
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part 
B. 
 
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 Benztropine tablets for the 
enrollee.  
 Benefits for self-administered drugs B 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen testing provided on September 26, 
2020. 
 
You asked the Plan to pay for the pathogen testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says the POS code reported is not correct. 
 
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. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the pathogen testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the respiratory pathogen testing provided on September 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been an attempt at a four week trial with a standard device. 
 
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 pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records do not show that the enrollee has failed a four week trial with a standard pump to 
indicate the necessity of the segmented pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryosurgery for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been attempted radiation therapy for treatment. 
 
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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has not received primary therapy for prostate cancer.  
 Guidelines from the American Society of Clinical Oncology (ASCO)] say that whole-gland cryosurgery should 
be limited to men with low-risk, clinically localized prostate cancer who are not suitable for either radical 
prostatectomy or RT due to comorbidities, yet who have a more than 10-year life expectancy. This enrollee is 
intermediate risk. The service 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryosurgery for the enrollee.