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

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20611 and 99204) 
provided to the enrollee on June 28, 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 records do 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 20611: 
 
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
with ultrasound guidance, with permanent recording and reporting 
 
 
 CPT 99204: 
 
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically 
appropriate history and/or examination and moderate level of medical decision making. When using time for 
code selection, 45-59 minutes of total time is spent on the date of the encounter 
 
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 suported by the medical records. Our reviewer found that the medical records provided does 
not include sufficient documentation to validate that an arthrocentesis, aspiration and/or injection, major joint 
or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting was performed on June 28, 2022; therefore, this procedure cannot be verified. Additionally, the 
medical records provided do not include sufficient documentation to validate CPT 99204-25 was performed as 
a significant, separately identifiable service; therefore, the service is included in the global day period of CPT 
20611 billed on the same date by the same provider. No additional reimbursement would be allowed. 
 
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 surgical services (procedure codes 20611 and 99204) provided to the enrollee on June 28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance angiography (MRA) of the head (70544). 
 
You asked the Plan to pre-approve an MRA of the head. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that MRA is considered appropriate when it can replace a 
more invasive test (e.g., contrast angiography) and reduce risk for beneficiaries. 
 
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 an MRA of the head. Our reviewer says 
that the services are medically necessary. Our physician reviewer found approximately 25% of brain aneurysms 
are hereditary. The fact this enrollee's brother has recently been discovered to suffer from such a lesion is 
adequate history and a valid indication for screening this enrollee for the same. The requested MRA is the most 
sensitive, non-invasive means by which to offer such a screen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the head have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance angiography (MRA) of the head (70544).  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided July 7, 2022. 
 
You asked the Plan to pay for the TENS supply allowance. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider's 
office indicated on the claim and verified that there is no electrical stimulator order on file. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supply 
allowance (A4595) provided July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the brain (70553) 
and an MRI of the cervical spine (72141). 
 
You asked the Plan to pre-approve an MRI of the brain and cervical spine. You say that you disagree with the 
denial. The Plan denied your request. The Plan says in the absence of signs or symptoms that are related to the 
brain and cervical spine, the MRI of the brain and MRI of the cervical spine that were ordered are not 
reasonable and necessary in this case. The request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the brain and cervical spine. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is 
noted to have complaints only involving the lumbar spine. The MRI of the lumbar spine has been previously 
approved by the Plan. The medical records provided for review made no mention of a plan to perform imaging 
on the brain or cervical spine. The enrollee reported no symptoms that localized to these areas. There were no 
findings on exam that would otherwise make such imaging studies "reasonable and necessary" for these 
anatomical areas. Therefore, the MRI of the brain and MRI of the cervical spine would not meet criteria for 
coverage. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain and cervical spine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the brain (70553) and 
an MRI of the cervical spine (72141).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 20, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 
93976. 
 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 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 20, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services (99292) provided on November 25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the add-on code 
was not billed with a primary code. 
 
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. The Plan argues that a primary code was not billed. The records show that code 
99291 was billed and paid for the same date of service. As such, add-on code 99292 is payable in this case. The 
Plan has not provided documentation substantiating its denial. Therefore, we decided that the Plan has to pay 
for the services (99292) provided on November 25, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vestibular function tests provided on October 3, 2022 and 
October 19, 2022. 
 
You asked the Plan to pay for vestibular function tests. You say that there is no other diagnosis to add to this 
service. The Plan denied your request. The Plan says the services were not preauthorized and do not comply 
with the diagnosis. 
 
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 vestibular function tests have been 
met. Specifically, there are no medical records provided for us to confirm that Medicare coverage criteria have 
been met. Therefore, we decided that the Plan does not have to pay for vestibular function tests provided on 
October 3, 2022 and October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 38222, 77002, and 99152 billed for date of service 
August 26, 2022. 
 
You asked the Plan to pay for codes 38222, 77002, and 99152. 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 38222, 77002, and 99152 are not supported in the medical record. Specifically, these 
codes were billed with manifestation diagnosis code D63.8 (Anemia in other chronic diseases classified 
elsewhere) as the primary diagnosis. Manifestation diagnosis codes are never permitted to be used as first listed 
or principal diagnosis codes. This means the claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of codes 38222, 77002, and 99152 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 38222, 77002, and 99152 billed for date of service August 
26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (87511, 87481, 87491, 87529, 87591, 87640) provided 
on June 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that additional information is needed to review medical necessity. 
 
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. The Plan required medical records to review the claim for medical necessity. We 
found no evidence in the case file that requests were sent to the provider for this additional information. Thus, 
we cannot verify that the Plan has made reasonable and diligent efforts to gather this information. Therefore, 
we decided that the Plan has to pay for the lab services (87511, 87481, 87491, 87529, 87591, 87640) provided 
on June 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (eo), with adjustable position locking 
joint(s), prefabricated, off-the-shelf proivded to the enrollee on August 31, 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 documentation did not sufficiently support the billed supply code. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesn't clearly indicate that the enrollee had a medical condition that 
required an elbow orthosis. 
 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 an elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf 
proivded to the enrollee on August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal disorders (FTD). 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has memory loss and Alzheimer's disease. The record does not indicate that the enrollee meets the 
criteria for both frontotemporal dementia and Alzheimer's disease or is enrolled in a clinical trial. The elements 
of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TULSA non-invasive procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental and not a standard of care. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the TULSA procedure is considered experimental and not a standard of care. Early 
oncologic outcomes following TULSA treatment of primary prostate cancer are favorable, however longer-
term studies and comparative studies are lacking in the medical literature. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the TULSA non-invasive procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network approval for neurology. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee could not get an appointment with the 
in-network provider you were approved for. The Plan denied your request. The Plan says the medical group has 
provided a list of equally qualified in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network approval for neurology.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided July 9, 2022. 
 
You asked the Plan to pay for the TENS supply allowance. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised ability without the option for surgical correction. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
office and was informed that there was no order made by the doctor for this enrollee. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supply allowance 
(A4595) provided July 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; not otherwise specified (00731) provided May 2, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you are an anesthesia provider and you bill 
separate from other providers. Please review the attached info and reprocess the info for reprocessing. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the members terminal condition.  
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 anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; not otherwise specified (00731) provided May 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provide don July 9, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
submitted did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the electrical stimulator supplies provide don July 9, 2022.