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

 
We decided that the Plan does not have to pay for procedure code 22633 rendered on March 23, 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 procedure code 22830 is considered inclusive to CPT 22633. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not support CPT 22830: exploration of spinal fusion as a separate and distinct procedure 
from CPT 22633: arthrodesis, combined posterior or posterolateral technique with posterior interbody 
technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for 
decompression), single interspace and segment.  The procedure details site the L4-5 and L5-S1 levels were exposed. A central, bilateral lateral recess and bilateral wide decompression was performed at the L4-5 level. 
The right-side facet screw with washer was removed and positioned in a fashion that would hinder pedicle 
screw placement at L5 on the right and therefore screw was removed. Posterior exploration of the fusion at the 
L5-S1 level demonstrated solid contiguous fusion mass present without motion present with stressing. The 
exploration of the fusion was performed while in the process of preparing the disc spaces for the L4-5 
interbody fusion/arthrodesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 22633 rendered on March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from November 11, 
2022, to November 12, 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 this is more appropriate as observation status. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the record did not show that at the time of inpatient admission it was 
reasonable for the admitting physician to expect that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights with supporting documentation of 
the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse 
event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered from November 11, 2022, to November 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services received on May 11, 2023. 
 
You asked the Plan to pay for the services. You say that this is not a cosmetic issue, rather an issue of 
unacceptable pain. The Plan denied your request. The Plan says routine foot care is statutorily excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pay for the services. Our reviewer says that 
the requested services are not medically reasonable or necessary.. Our physician reviewer found that in this 
particular case, the medical examination dated 5/11/23 demonstrates 2/4 pedal pulses with neurologic status 
grossly intact to light touch and Semmes Weinstein monofilament needle. It does not appear that this enrollee meets the coverage guidelines for routine foot care.. Therefore, we decided that the Plan does not have to pay 
for podiatry services received on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wipes. 
 
You asked the Plan to pre-approve wipes. You say that you are bed bound and have received them before in the 
past. The Plan denied your request. The Plan says wipes are not generally used primarily for health care, as 
they are regularly and primarily used by persons who do not have a specific medical need for them. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve wipes.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device at L5-S1. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the enrollee needs this surgery. The Plan 
denied your request. The Plan says records do not show why the enrollee is not able to have other types of 
surgeries to relieve pressure. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no current examinations provided to corroborate any subjective complaints 
or objective findings or the indication of failed conservative treatments. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the Vertiflex Superion interspinous spacer at L5-S1, in this case, is not medically reasonable or 
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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device at L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressing (A6209) provided on May 11, 2023. 
 
You asked the Plan to pay for the dressing room. The Plan denied your request. The Plan says this code was 
billed without the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claims lines for A6209 billed without A1-A9 
modifiers will be rejected as missing information. 
 
We looked at the file and Medicare rules. In this case, code A6209 was billed without a required modifier. 
Based on this information, we decided that Medicare rules for coverage of the dressing room have not been 
met. Therefore, we decided that the Plan does not have to pay for the wound dressing (A6209) provided on 
May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 chiropractic visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the chiropractic visits. You say that there is no one within driving distance. 
The Plan denied your request. The Plan says these services can be provided 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 
12 chiropractic visits to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on March 13, 2023, and billed with codes 87798, 87663, 87486, 87581, 87640, and 87651. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory polymerase chain reaction 
(PCR) panel provided on March 13, 2023, and billed with codes 87798, 87663, 87486, 87581, 87640, and 
87651.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection. 
 
You asked the Plan to pre-approve the PRP injection. The Plan denied your request. The Plan says this is not a 
covered service 
 
The Plan must follow Medicare rules. Medicare rules say that PRP injection and PRP combined with stem cells 
for musculoskeletal injuries and/or joint conditions, whether primary or adjunctive use, not medically 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Per LCD L39058, the requested PRT injection is not medically 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the PRP 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich 
plasma (PRP) injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each nivolumab injection provided on 
May 12, 2023, to June 01, 2023. 
 
You asked the Plan to reduce the coinsurance for each nivolumab injection. You say that you cannot afford the 
copayment 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for each nivolumab injection. This item/service falls within the Medicare Part B prescription 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 reduce the coinsurance for 
each nivolumab injection provided on May 12, 2023, to June 01, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for evaluation and management services (procedure code 99214) rendered 
on March 27, 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 that 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 
code 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records support a medically 
appropriate history and examination. The records support a moderate level of medical decision making. CPT 
99214 is significant, and separately identifiable from CPT 96372. 
 
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 
evaluation and management services (procedure code 99214) rendered on March 27, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on March 
1, 2023. 
 
You asked the Plan to pay for 95937. You say that this was medically necessary. The Plan denied your request. 
The Plan says this code is not supported by the 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 95937 is neuromuscular junction testing, each nerve, any 
1 method. 
 
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 95937. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found this code cannot be reported separately and is included in the intraoperative neuromonitoring services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95937 have not been met. Therefore, we decided that the Plan does not have to 
pay for neuromuscular junction testing (95937) provided on March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that without rehabilitation you could potentially fall and 
be at risk of losing life or another limb and you need to learn how to walk. The Plan denied your request. The 
Plan says your condition does not meet the Medicare guidelines.  The Plan says that the services needed may 
be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with an 
incorrect date of service; laboratory services should be reported with the date of specimen collection as the date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the specimen in this case was a tissue 
sample which would have been collected during a medically necessary and appropriate hospital stay, and the 
test itself was performed after discharge. Based on the documentation provided, one of the exceptions has been 
met, which means that the appropriate date to report in this case would be the date the test was performed. In 
this case, the correct date is April 27, 2023. Therefore, we decided that the Plan has to pay for Breast Cancer 
Index testing (81518) billed for date of service April 27, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service April 4, 
2023. 
 
You asked the Plan to pay for procedure code 95937. 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 records provided. 
 
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 95937  is neuromuscular junction testing (repetitive 
stimulation paired stimuli) each nerve, any 1 method. 
 
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 95937. Our reviewer says that this code is 
not supported in the medical records provided. Our reviewer found CPT code 95937 is used for neuromuscular junction testing and should not be used for Train of Four (TOF) Monitoring. A CPT code does not exist for 
Train of Four as this procedure is inclusive of the primary neuromonitoring 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 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for August 23, 2022, to September 21, 2022. 
 
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. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for 
August 23, 2022, to September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 21, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 11, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 11, 2023.