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

 
We decided that the Plan does not have to pay for the comprehensive periodontal examination (code D0180) 
you received on January 3, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal examination. You say that this exam was done to 
ascertain a diagnosis and determine the appropriate dental services to be rendered. The Plan denied your 
request. The Plan says this is not a covered service under your dental benefit. 
 
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 Plan's dental benefit 
includes coverage only for those services and codes listed in your dental benefits chart.  Comprehensive 
periodontal examinations (code D0180) are not listed as covered services in this chart. 
 
 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. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal examination (code D0180) you received on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81201, 81317, 81404, 81405, and 
81406) provided on March 14, 2021. 
 
You asked the Plan to pay for codes 81201, 81317, 81404, 81405, and 81406. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81201, 81317, 81404, 81405, and 81406) provided on March 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81238, 81220, 81225, 81230, 81227, 
81355, 81241, 81291, and 81240) provided on July 2, 2021. 
 
You asked the Plan to pay for codes 81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291, and 81240. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says the services are not covered 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291, and 81240) 
provided on July 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol Tartrate (J7605). 
 
You asked the Plan to pre-approve Arformoterol Tartrate. You say that the enrollee does not have enough 
breath to inhale other medicines. You also say that the nebulized medications work best for this enrollee. The 
Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for 
Brovana. 
 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 Arformoterol Tartrate. Our reviewer 
says that Arformoterol Tartrate is not medically reasonable and necessary. Our physician reviewer found the 
records do not include documentation of trial and failure of Perforomist. Step therapy may only be applied to 
new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected 
medication. Our reviewer also found that the clinical documentation in the case file supports that the enrollee is 
actively receiving the requested medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arformoterol Tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol Tartrate (J7605).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on December 23, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for anesthesia services is made to the 
physician who personally performed the entire anesthesia service alone or a qualified nonphysician anesthetist. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the anesthesia services were not performed by a 
physician or qualified nonphysician anesthetist. 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 
anesthesia services rendered on December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no qualifying diagnosis of bronchiectasis, cystic fibrosis or neuromuscular 
disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested device is not medically reasonable or necessary.  Our physician reviewer found the enrollee has COPD and asthma. There is no bronchiectasis on the chest 
computed tomography (CT) scan, and no evidence of a diagnosis of cystic fibrosis or neuromuscular disease. 
There is no convincing evidence of benefit in the treatment of COPD or asthma.  
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive metabolic panel provided on January 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a comprehensive metabolic panel. You say that the medical records support the 
charges. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
  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 comprehensive metabolic panel provided on 
January 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 14, 
2021. 
 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 CPT 01610: 
 
Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla 
 
CPT 99100: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
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 CPT 01610 is not 
supported by the medical records. Our reviewer found that in this case, there are more appropriate CPT codes 
that should be used to bill for the service provided; therefore, the billed service cannot be verified. CPT code 
01610 is unsupported. 
 
We looked at this coder's review, the file, and Medicare rules. Our coder found that CPT 01610 is not 
supported. Additionally, CPT 99100 is not supported as being able to be reported separately, as it has a status 
indicator of "B." 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 provided to the 
enrollee on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 17, 2021. 
 
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 coding guidelines have not been met. 
 
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 additional payment for additional renderings of CPT codes 71275 and 74177 are not supported in 
the medical record. Specifically, the records show that these services were only rendered once in this case. 
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 additional imaging services provided to the 
enrollee on October 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-abdominal omental flap provided to the enrollee on 
February 8, 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 procedure code 49905-82 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 49905 is "Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure)." 
 
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 the operative report does not include 
documentation of an Omental flap for reconstruction of a defect.  Operative report describes repair of bowel 
anastomosis, in this case, a repair would be included in the repair procedure. Therefore, an omental flap cannot 
be confirmed as performed.  
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 an intra-abdominal omental flap provided to the enrollee on February 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Atezolizumab provided to the enrollee on December 14, 2021. 
 
You asked the Plan to pay for the drug. You say that this should be paid for. The Plan denied your request. The 
Plan says that this does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the drug. Our reviewer says that the services 
at issue in this case were not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of extensive stage small cell lung cancer and symptomatic malignant 
pleural effusion and has completed induction therapy with the requested agent and carboplatin and etoposide. 
The Medicare-approved cancer drug compendia do contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. The elements of the coverage criteria are satisfied. 
 
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 drug have been met. Therefore, we decided that the Plan has to pay for 
Atezolizumab provided to the enrollee on December 14, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that evidence of safety and efficacy should be present in the medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee meets criteria for both anterior and posterior spinal surgery. There is multilevel cervical 
myelopathy, and the surgery involves at least three levels of anterior fusion. Therefore, posterior surgery is 
needed to prevent failure of fusion. Both anterior and posterior surgery should be approved. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve spinal surgery for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 17, 
2021. 
 
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 27335: 
 
Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area 
 
CPT 20680: 
 
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 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 in terms of CPT 27335, 
synovectomy would be included in the primary procedure, total knee arthroscopy, when performed on same 
anatomical area. When the documentation supports a procedure is above and beyond, an appropriate modifier 
would be appended would be appended. In terms of CPT 20680, the operative report describes removal of a 
screw, after insertion of a fixation, due to (per operative report) "not seating well as this was entering the 
box."  In this case, this procedure would be inclusive to the primary 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 surgical services provided to the enrollee on November 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three home health physical therapy (PT) visits for the 
enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that all physical therapy goals have been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that in this case, the 
documentation doesnt support that the enrollee requires additional skilled rehab services to provide treatment 
that is medically necessary. The enrollee does not require additional skilled nursing  services to effectively 
provide treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance 
program to maintain the members condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home 
health services are not 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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve three home health physical therapy (PT) visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee from May 26, 
2021 to June 2, 2021. 
 
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 billed DRG and diagnosis codes. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the services. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found additional work-up for this stay in included a 
gastroenterology consultation for possible gastric outlet obstruction, however the esophagogastroduodenoscopy 
(EG) did not confirm this diagnosis. While the physician also included a diagnosis of acute on chronic diastolic 
heart failure in the discharge summary, the clinical evidence did not support the condition. The review has 
determined that the records did not support the billing of DRG 871 and diagnosis code I50.33.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided to the enrollee from May 26, 2021 to June 2, 2021.