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

 
We decided that the Plan does not have to pay for procedure code 99213 for date of service June 16, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27530 
and 24586 provided on May 25, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213 
for date of service June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient surgery (66984) provided on 
April 18, 2023. 
 
You asked the Plan to reduce the copayment for the outpatient surgery (66984). You say that the cost share was 
applied incorrectly. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery. 
 
You have been asked to pay a $275 copayment for the outpatient surgery (66984). This item/service falls 
within the outpatient surgery 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 reduce the copayment for the 
outpatient surgery (66984) provided on April 18, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 37211-XU. We decided that the Plan does not have to pay for 
code 75710-XU.  
 
You asked the Plan to pay for codes 75710-26-XU and 37211-XU billed for date of service March 2, 2023.. 
You say that medical records were provided to support payment. The Plan says that the use of the XU 
modifiers to allow for separate payment of codes 75710-26-XU and 37211-XU is not supported by the medical 
records. The medical records don't support that these codes are distinct or independent from other services 
performed. 
 
We decided that the Plan has to pay for code 37211-XU.  
 
The Plan follows Medicare rules. Medicare rules say that providers must bill services correctly.  Providers may 
use the XU modifier to bypass a NCCI edit when the medical records show that the service is distinct because 
it does not overlap usual components of the main service. 
 
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 codes 75710-26-XU and 37211-XU. Our 
reviewer says that the use of the XU modifier with code 37211 is supported by the medical record, but not for 
code 75710. Our physician reviewer found for code 37211-XU, the documentation supports that this service 
was performed with the ultrasound, which differs from code 37814 in that it is percutaneous.  However, for 
code 75710-XU, the medical records do not document that an angiography was performed, so this code cannot 
be supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 37211-XU have been met. Therefore, we decided that the Plan has to pay 
for code 37211-XU.  
 
 We also decided that the Plan does not have to pay for code 75710-XU. 
 
As discussed above, our physician reviewer found that for code 75710-XU, the medical records do not 
document that an angiography was performed, so this code cannot be supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 75710-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 75710-XU. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 20, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was prior to the patient being 
admitted into hospice. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 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. Please note 
that the hospice election period begins on the day that hospice is elected, regardless of the time of day of the 
election. Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 20, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided June 20, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR testing is 
considered unproven and not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing provided June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) billed for 
dates of service March 16, 2023, to April 4, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not covered. The Plan must 
follow Medicare rules. Medicare rules say that fluid circulating cold pads with pump (E0218) are non-covered. 
Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) 
billed for dates of service March 16, 2023, to April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant for multiple veins. 
 
You asked the Plan to pre-approve injection of sclerosant. You say that the enrollee has utilized conservative 
therapies for several years. The Plan denied your request. The Plan says that the enrollee does not meet medical 
necessity guidelines for this service. 
 
The Plan follows Medicare rules. Medicare rules say that this treatment may be covered under certain 
circumstances. 
 
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 injection of sclerosant. Our reviewer 
says that the documentation does not meet coverage criteria. Our physician reviewer found that for tributary 
treatment such as sclerotherapy to be considered medically necessary per coverage criteria, there needs to be 
persistent significant symptoms following successful treatment of truncal (saphenous) reflux with these 
symptoms existing more than 6 weeks after the reflux was treated and despite conservative efforts.  
Additionally, the veins to be treated need to be at least 4 mm in diameter. As the enrollee has not yet undergone 
saphenous vein reflux treatment, the above criteria have not been met. The health plan does not provide for 
simultaneous saphenous reflux treatment and tributary treatment. A rationale for this is that many patients 
experience satisfactory relief with the truncal intervention alone. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of sclerosant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection of sclerosant for multiple veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2022, billed 
with codes 87481, 87500, 87640, 87652, and 87798. 
 You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. There 
are insufficient medical records that document the need for testing and how it will impact clinical management. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 16, 2022, billed with codes 87481, 87500, 87640, 87652, and 87798.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an electronic knee and advanced foot feature. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that activity needs can met with a mechanical knee. 
 
The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that not only does the medical record go above and beyond in satisfying Medicare policy by 
demonstrating this enrollee has K3 functional level potential and has specific needs for the requested 
components, but the plan also attempts to create a more restrictive policy for defining K3 function than 
Medicare policy would allow. 
 
The plan's denial letter sets more stringent requirements than Medicare. In its own definition of the K3 level, 
the Plan seeks to create strict use-case criteria with a level of specificity that does not appear in the LCD. The 
Medicare K3 criteria is broad and inclusive and generally describes the average Medicare enrollee who lives 
independently at home and in the community. 
 Regarding the criteria for coverage of the component still in contention, LCD L33787 states simply, A fluid, 
pneumatic, or electronic/microprocessor knee...is covered for beneficiaries whose functional level is 3 or 
above. No further specific documentation is required in the LCD, the Policy Article, or any of the relevant 
Medicare manuals because Medicares policy recognizes that microprocessor knees are part of the basic 
standard of care for all community above knee amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. In the case of this enrollee, 
and all comparable K3 ambulators, lesser devices simply do not meet her functional needs and would amount 
to substandard care.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a prosthetic leg with an electronic knee and advanced foot feature.  
 
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 procedure code 95955 provided on April 28, 2023. 
 
You asked the Plan to pay for procedure code 95955. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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. 
 
In this case, the CPT Code Manual definition of code 95955 is electroencephalogram during non-intracranial 
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 procedure code 95955. Our reviewer says that the records do 
not support the code billed. Our reviewer found the records did not provide any electroencephalogram readings 
or interpretation for the billed date of service.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95955 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95955 provided on April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens (A-C 
IOL) (V2787). 
 
You asked the Plan to pay for the A-C IOL. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism 
correcting function of intraocular lens (A-C IOL) (V2787).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the coverage criteria for Euflexxa. Our physician reviewer found the Plan requires a trial 
of Orthovisc or Supartz FX before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. Our reviewer also found that there is no documentation provided indicating that 
the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing (87637) provided December 28, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you are requesting reconsideration of the 
claim. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the 
service and that the coverage criteria has been met. 
 
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 the laboratory testing have been met. 
Additional medical records were requested from the provider. The record show that the Plan made multiple 
attempts to obtain the needed records from the provider without success. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing (87637) provided December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 99285 rendered on February 21, 
2023. 
 
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 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
 CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records support a medically 
appropriate history and examination; however, they do not support a high level of medical decision making. 
There is no documentation that an ECG was completed and interpreted. 
 
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 procedure codes 93010 and 99285 rendered on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the criteria for an LTACH admission has not been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation indicating medical necessity for admission to an 
LTACH. The enrollee does not require services at the LTACH that are not already available at the current 
facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee, and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab and imaging services coded as 82150, 82565, 83690, 
84520, 82947, 83036, 86301, and 74183 billed on April 10, 2023.  
 
You asked the Plan to pay for the lab and imaging services. You say that the lab and imaging services should 
be paid as billed because they were medically necessary. The Plan denied your request. The Plan says the 
records provided to support the lab and imaging services are not sufficient, and no additional records were 
received despite multiple requests. 
 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. The records provided in this case do not show the billed imaging was 
done, nor do they show the results of the lab testing. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the lab and imaging 
services have been met. Therefore, we decided that the Plan does not have to pay for the lab and imaging 
services coded as 82150, 82565, 83690, 84520, 82947, 83036, 86301, and 74183 billed on April 10, 2023.