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

 
We decided that the Plan does not have to pay for arthroscopy, knee, surgical; synovectomy, major, 2 or more 
compartments (eg, medial or lateral) rendered on July 29, 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 procedure code 29876-LT 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 29876 is "Arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (eg, medial or lateral)." 
 
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 details cite the 
hypertrophic hyperemic synovial tissue was debrided from the suprapatellar compartment, medial and lateral 
gutters, and the subpatellar area and notch. The overgrown, inflamed synovial tissue was resected. This 
supports that 2 or more compartments were debrided. Therefore, the records do support that CPT 29876 was 
rendered in this case. 
 
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 arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or 
lateral) rendered on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on December 16, 2022, by an 
OON provider. 
 
You asked the Plan to pay for chiropractic services. You say that you disagree with the denial of this claim. 
The Plan denied your request. The Plan says that chiropractic services are not covered by an out-of-network 
provider. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you can obtain certain out-of-network services through the POS benefit, however out-of-network 
chiropractic services are not covered. 
 
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. 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 
chiropractic services provided on December 16, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field assessment provided on November 19, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the visual field assessment. You say that this assessment was medically 
necessary. The Plan denied your request. The Plan says that this service was not authorized. 
 
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 visual field assessment provided on November 
19, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Restasis.   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on December 28, 2022, by an 
out-of-network (OON) provider. 
 You asked the Plan to pay for wound care supplies. You say that the services should be covered. The Plan 
denied your request. The Plan says the provider is out-of-network and there was no authorization for the 
services. 
 
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 wound care supplies provided on December 28, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on August 10, 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 Current Procedural Terminology (CPT) code 99285 (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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 did not support that 
the presenting problems were of high severity, posing an immediate significant threat to life and function. 
 
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 emergency department services (procedure code 99285) rendered on August 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 22830 and 22845 rendered on October 7, 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 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 22830: 
 
Exploration of spinal fusion 
 
CPT 22845: 
 
Anterior instrumentation; 2 to 3 vertebral segments (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 supported by the medical records. Our reviewer found that the procedure details cite the plate 
was removed. The locking mechanism was disengaged and the screws removed and the plate was removed 
easily. The fusion was inspected and appeared solid. Distraction was tried through the two screw holes and 
there was no motion at all at the fusion site. The holes where the screws were, were packed with bone 
wax. Then the posterior aspect of C6 and C7 was undercut and the thickened posterior longitudinal ligament 
was removed and decompression at the foramen was carried out. The plate was centered over the cage and bur 
holes were made and the screw placed. The locking mechanism was engaged. The drain was placed and the 
incision was closed. The placement of the plates, screws, and locking mechanism at C6-7 was performed after 
the removal of the previous fusion instrumentation at C5-6. The previous instrumentation at C5-6 was removed 
and a solid fusion was noted. (This was not part of the needed fusion/instrumentation at C6-7.) Therefore, the 
records do support CPT 22845: anterior instrumentation 2-3 vertebral segments (spinal fusion, lumbar) as a 
separate and distinct procedure from CPT 22855: removal of anterior instrumentation. 
 
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 codes 22830 and 22845 rendered on October 7, 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 27, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 27, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981) and an axial rotation unit 
(L5986). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a prosthesis with a K3 foot does not meet the criteria as reasonable and 
necessary. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's current foot is still under warranty without irreparable damage. The documentation 
does not support that the enrollee is a K3 ambulator given the need for an assistive device, limited knee and hip 
range of motion and weakness at the hips and lack of functional need of a K3 foot. The K3 foot exceeds the 
enrollee's needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a flex walk system (L5981) and an axial rotation unit (L5986).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 18, 2022, to 
July 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the medical records provided 
support the need for the home health services. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 18, 2022, to July 
13, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to approve for PT services provided from November 21, 2022, to December 12, 
2022, by an out-of-network provider. 
 
You asked the Plan to approve for PT services. You say that the member is recovering from a stroke, which 
requires therapy to improve overall function and strength. The Plan denied your request. The Plan says that the 
member has exceeded the $3,000 maximum for PT services and a prior authorization was not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to provide a valid denial reason. The contract states a 
prior authorization for PT services beyond $3,000 applies to in-network providers; however, the PT services 
you received were performed by an out-of-network provider and you are not required to submit a prior 
authorization for services rendered by out-of-network providers. Therefore, we decided that the Plan has to 
approve for PT services provided from November 21, 2022, to December 12, 2022, by an out-of-network 
provider.  
 
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 anesthesia for intraperitoneal procedures in lower abdomen 
including laparoscopy; not otherwise specified rendered on June 27, 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 Current Procedural Terminology (CPT) code 00840 QK (165 units) 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 00840 is "Anesthesia for intraperitoneal procedures in 
lower abdomen including laparoscopy; not otherwise specified." 
 
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 there is no documentation of the 
hernia being incarcerated or strangulated. The surgical/operative note was not submitted. The anesthesia report 
documents ventral hernia - without notation of obstruction. The medical records indicate anesthesia for hernia 
repairs in lower abdomen; ventral hernia that was performed, in this case. The remittance sheet documents that 
CPT 00840 was billed. However, there is a more appropriate Current Procedural Terminology (CPT) code 
00832 that should be used to bill for the service provided. Without the documentation of a reducible vs 
irreducible hernia repair, CPT 00840 is not supported. 
 
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 anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not 
otherwise specified rendered on June 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75716 and 75774 rendered on September 
29, 2022. 
 
You asked the Plan to pay for the services. You say that additional documentation was sent in. 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 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation  
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (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 that the documentation does not 
support coverage of the codes as coded. CPT 75716 codes for the supervision and interpretation of bilateral 
extremity angiography. There is satisfactory documentation that a right lower extremity angiogram was 
performed and interpreted.  However, there is unsatisfactory documentation of left lower extremity 
angiography to justify use of this code. As there is no evidence of a previous angiogram, diagnostic 
angiography in this setting would be separately reportable and billable using a more appropriate code for 
unilateral extremity angiography. In terms of CPT 75774, this is an add-on code coding for the supervision and 
interpretation of selective additional vessels beyond the base code. In this case, there is no documentation of 
additional vessels being selectively interrogated beyond the right lower extremity. Therefore, the 
documentation does not support use of this code. 
 
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 75716 and 75774 rendered on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on April 26, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that this service was 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 a chest x-ray provided 
on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), periodic oral 
evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental office told you they have several 
insurances that are not in-network, but they pay a portion of the bill. You also say that you are asking the Plan 
to do the same so they don't have to charge the dentists. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided on January 10, 2023.