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

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95927 billed for date of service 
March 29, 2022. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says these codes 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. 
 
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 procedure report describes a 
neuromonitoring service provided for anterior cervical discectomy and fusion (ACDF) at C6-C7. In this case, there is a more appropriate code that should be reported. Therefore, CPT 95822 cannot be verified. 
 
In terms of CPT 95927, the procedure report does not include documentation of this service. This procedure 
was not found in the medical records. 
 
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 95822 and 95927 billed for date of service March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 billed for date of service April 6, 
2023.  
 
You asked the Plan to pay for the service. You say that this service was necessary and was reported 
appropriately.  The Plan denied your request. The Plan says this code is 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 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional. 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report does not include sufficient documentation to 
confirm technical component of service provided. Code 93229 is the technical component of this service and 
includes all of the following within a course of treatment that includes up to 30 consecutive days of cardiac 
monitoring: Patient hook-up and patient-specific instruction and education. The documentation does not 
support attended surveillance person 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 93229 billed for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physician services. You say that it is medically necessary. The Plan denied 
your request. The Plan says physicians are available, and services can be performed safe in your local area. 
 
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 
physician services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the necessary services may be obtained in-network. 
 
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 office visit to be provided by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has ankylosing spondylitis. 
She has not tried and failed the Plan's required drugs, Remicade, Infliximab, Inflectra, or Simponi Aria. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Avsola is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Avsola.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve hereditary cancer testing. You say that you have extensive family history of 
breast cancer and feel this test will impact your future care. The Plan denied your request. The Plan says 
genetic testing is not medically necessary in this case as you do not have a personal history of cancer. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary cancer testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the emergency room visit, and each drug 
injection provided from December 2, 2022, to December 28, 2022. 
 You asked the Plan to waive the cost share for the emergency room visit and each drug injection. You say that 
you are not responsible for these amounts. 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 $90 
copayment for each emergency room visit. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
Date of Service CPT Code Allowed Amount Copayment Coinsurance 
December 2, 2022 Q4081 $31.04 - $6.21 
December 2, 2022 J1644 $35.42 - $7.08 
December 5, 2022 Q4081 $31.04 - $6.21 
December 5, 2022 J1644 $35.42 - $7.08 
December 5, 2022 J1756 $41.47 - $8.29 
December 7, 2022 Q4081 $31.04 - $6.21 
December 7, 2022 J1644 $35.42 - $7.08 
December 9, 2022 Q4081 $31.04 - $6.21 
December 9, 2022 J1644 $35.42 - $7.08 
December 12, 2022 Q4081 $31.04 - $6.21 
December 12, 2022 J1644 $35.42 - $7.08 
December 14, 2022 Q4081 $31.04 - $6.21 
December 14, 2022 J1644 $35.42 - $7.08 
December 16, 2022 Q4081 $35.18 - $7.04 
December 16, 2022 J1644 $35.42 - $7.08 
December 19, 2022 Q4081 $35.18 - $7.04 
December 19, 2022 J1644 $35.42 - $7.08 
December 21, 2022 Q4081 $35.18 - $7.04 
December 21, 2022 J1644 $35.42 - $7.08 
December 23, 2022 Q4081 $35.18 - $7.04 
December 23, 2022 J1644 $35.42 - $7.08 
December 26, 2022 Q4081 $35.18 - $7.04 
December 26, 2022 J1644 $35.42 - $7.08 
December 27, 2022 99285 $679.52 $90 - 
December 28, 2022 Q4081 $35.18 - $7.04 
December 28, 2022 J1644 $35.42 - $7.08 
Total $262.75 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay 20% coinsurance for each drug injection. 
This item/service falls within the Medicare Part B drugs benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost share for the emergency room visit, and each drug injection provided from December 2, 2022, to 
December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 298 units of procedure code 00567 provided on August 24, 
2022. 
 
You asked the Plan to pay for 298 units of procedure code 00567. You say that the medical records support the 
billing of 298 units of procedure code 00567. The Plan denied your request. The Plan says the medical records 
do not support the billing of 298 units of procedure code 00567. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 298 units of procedure code 00567. Our 
reviewer says that the medical records do not support the billing of 298 units of procedure code 00567. Our 
physician reviewer found the provider reported 298 units for 296 minutes of anesthesia. Anesthesia time 
documents, start time 07:00 and end time 11:56.  In this case, the units of service billed is not 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 298 units of procedure code 00567 have not been met. A corrected claim should 
be submitted to the Plan for review. Therefore, we decided that the Plan does not have to pay for 298 units of 
procedure code 00567 provided on August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Urolift procedure. 
 
You asked the Plan to pre-approve the procedure. You say that clinical information was submitted with the 
appeal request to support medical necessity. The Plan denied your request. The Plan says the health plan has no 
contractual obligation to cover services that are not covered by Medicare. 
 
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 Urolift is not medically reasonable and necessary in this case. A uroflow study has not 
been done and the prostate is only 16 cc in size. Surgical and minimally invasive options should be considered 
when the individual has a peak urine flow rate (Qmax) less than 15 ml/sec on a voided volume that is greater than 125 ml). The American Urological Association (AUA) guidelines state that Urolift can be considered as a 
treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an 
obstructive middle lobe. In addition, this enrollee has had radiation for prostate cancer and cystoscopy has not 
been done to show the cause for his urinary symptoms (urethral stricture, bladder neck contracture, bladder 
dysfunction, etc.) 
 
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 Urolift procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 05, 2023. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient hospital care 
provided on March 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on March 22, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on February 08, 2023, to 
March 15, 2023. 
 
You asked the Plan to pay for psychotherapy visits. You say that this was medically necessary and should be 
covered. It has been covered before, as you are in-network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visits 
provided on February 08, 2023, to March 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sotyktu (J8499). 
 
You asked the Plan to pre-approve the medication. You say that Sotyktu is medically necessary for treating the 
enrollee's psoriasis. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sotyktu (J8499).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer 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 medical studies have not proven that this service is helpful for treatment of the 
health problem. 
 
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 clinical value and effectiveness of the VivAer procedure is insufficiently supported in 
the peer-reviewed literature. There is insufficient medical literature to support the safety and efficacy of this 
procedure compared with accepted surgical standards of care. The documentation does not sufficiently establish medical necessity and reasonableness in this case. 
 
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 VivAer procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95912 rendered on November 30, 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 that Current Procedural Terminology (CPT) code 95912 KX (1 Unit) remains 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 95912 is "Nerve conduction studies; 11-12 studies." 
 
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 supported by the medical records. Our reviewer found that the nerve conduction study 
corroborates sites of testing of right median- Digit III; right ulnar- Digit V; left ulnar- Digit V; right median- 
ulnar palmar (median and ulnar); left median-left palmar (median and ulnar); right radial-wrist, left radial- 
wrist; right ulnar-ADM; and left ulnar- ADM. There are documented 11 sites utilized for testing. Therefore, the 
records do support that 11-12 studies of nerve conduction studies were performed on this date. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 95912 rendered on November 30, 2022.  
 
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.