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

 
We decided that the Plan does not have to pay for the testing services (CPT code(s): 95908, 95886 and 95955) 
provided on May 20, 2022. 
 
You asked the Plan to pay for the testing services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95908 is nerve Conduction Studies 3-4 studies, code 
95886 is needle electromyography, per each extremity with related paraspinal areas when performed, done with 
nerve conduction, amplitude and latency/velocity study; for five or more muscles studied and code 95955 is electroencephalogram (EEG) during nonintracrainial surgery (carotid surgery) 
 
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 testing services. Our reviewer found for code 95908 - the 
documentation submitted was reviewed and does not meet criteria. The procedure report does not include 
documentation of nerve conduction studies which measure amplitude and latency/velocity. Procedure report 
describes "pedicle screw stimulation", which would not be reported with nerve conduction studies. For code 
95886  The documentation submitted was reviewed and does not meet criteria. Per code description, "done 
with nerve conduction studies", nerve conduction studies cannot be verified, as screw stimulation was 
performed.  Therefore, this procedure cannot be verified. For code 95955  The documentation submitted was 
reviewed and does not meet criteria. The procedure report does include documentation of additional EEG 
during nonintracranial surgery. Our reviewer was unable to cite report, as this procedure was not found in 
report, and therefore, 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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the testing services (CPT code(s): 95908, 95886 and 95955) provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two extractions (D7140) performed by an oral surgeon. 
 
You asked the Plan to pre-approve two extractions. You say that the extractions are medically necessary. The 
Plan denied your request. The Plan says services are not covered when received by an oral surgeon. 
 
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, the requested items or services are not 
among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve two extractions (D7140) performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 99221. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99221 is bundled into 
payment for codes 77263, 77290, and 77334. 
 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 99221 
is a column II code to column I codes 77263, 77290, and 77334. 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 99221 billed for date of 
service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 
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 physician services provided on June 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81321) provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services (81321). You say that you would like the Plan to reconsider their 
denial of payment. 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 (81321) provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 provided on February 9, 2022. 
 
You asked the Plan to pay for procedure code 87900. You say that the medical records support the billing of 
code 87900. The Plan denied your request. The Plan says the medical records do not support the billing of code 
87900. 
 
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 87900 is Infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87900. Our reviewer says that the medical records do not support the billing of code 87900. Our reviewer found the records submitted do not contain 
results supporting that drug susceptibility phenotype prediction using genotypic bioinformatics was performed. 
Although sensitivity testing was performed, the phenotype prediction using genotypic bioinformatics is not 
documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a bi-ventricular defibrillator (CRT-D). 
 
You asked the Plan to pre-approve implantation of a CRT-D. 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 implantable cardioverter defibrillators are covered 
when specific criteria are met. 
 
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 implantation of a CRT-D. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no evidence of a need 
for bradycardia pacing, nor evidence of left bundle branch clock. As such, guidelines would not support 
implant of a CRT-D. In summary, there is insufficient documentation to support the medical necessity for 
implantation of a CRT-D in this enrollee's management.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a CRT-D have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of a bi-ventricular defibrillator (CRT-D).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on July 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with he denial. The Plan denied your 
request. The Plan says procedure code 63081 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 63081 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single 
segment. 
 
We find that CPT code 63081 is not supported in the medical record. Specifically, the operative report does not 
include documentation of a partial or complete vertebral corpectomy using an anterior approach with decompression for a single cervical segment. 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 
surgical services rendered on July 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Varithena. 
 
You asked the Plan to pre-approve Varithena. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that the VCSS system includes 10 clinical descriptors 
(pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, 
duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3 (total possible 
score, 30) that may be used to assess changes in response to therapy. 
 
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 Varithena. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not meet coverage criteria and does not support the medical necessity of the treatments in question. Coverage criteria require that 
the enrollees symptoms be activity limiting despite efforts at conservative therapy. The documentation does 
not satisfactorily demonstrate that the enrollee is having activity limiting symptoms and does not demonstrate 
that a concerted effort at conservative care was recently attempted. Furthermore, it is not clear that the 
enrollees symptoms are due to the varicose veins. The enrollee has documentation of arthritis, chronic lumbar 
back pain, neuropathic pain, neuropathy, and numbness; these potential etiologies for lower extremity 
discomfort are not addressed in the rationale. Additionally, although the enrollee has undergone numerous 
endovenous procedures on the right including right great saphenous vein Varithena treatment, the right great 
saphenous vein is demonstrated to be normal on duplex, neither refluxing nor thrombosed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Varithena have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Varithena.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardioverter defibrillator (ICD) (33249). 
 
You asked the Plan to pre-approve an ICD. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee does not meet NCD criteria for approval of an ICD. 
 
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 an ICD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical necessity of implantation of a defibrillator in this enrollee with 
echocardiographic ejection fraction in 1/2023 of 36-40%. As such, the enrollee does not meet implant criteria 
for defibrillator insertion according to current guidelines. In the absence of such documentation, implantation 
of an automatic defibrillator would not be considered medically necessary in the management of this enrollee. 
 
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 ICD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable cardioverter defibrillator (ICD) (33249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on April 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 dental services provided by an out-of-
network provider on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid fitting (V5011), a digital, binaural hearing aid 
(V5261), a dispensing fee binaural (V5160), and a conformity evaluation (V5020) provided on February 23, 
2022. 
 
You asked the Plan to pay for hearing aid fitting (V5011), a digital, binaural hearing aid (V5261), a dispensing 
fee binaural (V5160), and a conformity evaluation (V5020). You say that you called the Plan and spoke with a 
representative who said that this provider is in-network. You also say that the representative said the enrollee 
had hearing aid benefits. The Plan denied your request. The Plan says there is no benefit for out-of-network 
providers. The Plan also says that this provider is not in-network with the Plan specific program. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids only when scheduled through the Plan hearing program. 
 
 We looked at the file, and the Plan's rules. The Plan rules say that you must contract the Plan hearing program 
to schedule an appointment with a contracted hearing provider. The Plan rules also say that the Plan hearing 
program will help you find a contracted provider. The record shows the enrollee went to an out-of-network 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aid fitting 
(V5011), a digital, binaural hearing aid (V5261), a dispensing fee binaural (V5160), and a conformity 
evaluation (V5020) have been met. Therefore, we decided that the Plan does not have to pay for hearing aid 
fitting (V5011), a digital, binaural hearing aid (V5261), a dispensing fee binaural (V5160), and a conformity 
evaluation (V5020) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye examination (92004), a determination of 
refractive state (92015), and fundus photography (92250) provided on May 3, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a new patient eye examination (92004), a determination of refractive state 
(92015), and fundus photography (92250). You say that the member came for his appointment and stated he 
has Medicare as his primary insurance. You also say that you submitted the claim not knowing prior 
authorization was required. The Plan denied your request. The Plan says services rendered by a non-
participating providers require prior authorization. The Plan also says the appeal was denied due to prior 
authorization required and not obtained. 
 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 a new patient eye examination (92004), a 
determination of refractive state (92015), and fundus photography (92250) provided on May 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stent placement. 
 
You asked the Plan to pre-approve stent placement. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 stent placement. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of peripheral vascular disease, the documentation does not 
confirm the presence critical limb ischemia, nor has there been a trial of medical therapy. In summary, there is 
insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stent placement have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stent placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a 3D photographic 
image (D0351) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service August 4, 2022. D0351 is not a covered dental 
benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a 
3D photographic image (D0351) provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface cover. 
 
You asked the Plan to pre-approve a protective outer surface cover. 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 lower limb prostheses are covered when specific 
criteria are 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 a protective outer surface cover. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found provided medical 
records do not document that the enrollee will be exposed to such an unusually harsh and difficult environment 
that the standard prosthetic cover would be inadequate for her needs. 
 
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 protective outer surface cover have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a protective outer surface cover.