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

 
We decided that the Plan does not have to pay for the office visit provided on May 10, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says 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 the office visit provided on May 10, 2023, by an 
OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 20, 2022, to August 
18, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 20, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 20, 2022, to August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service April 28, 
2023. 
 You asked the Plan to pay for the billed services. You say that the biopsy showed no abnormality. The Plan 
denied your request. The Plan says an appropriate primary diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 88305 was billed with a primary diagnosis code R13.10, defined as unspecified 
dysphagia. The medical records do show dysphagia as the diagnosis. However, diagnosis code group R13.1- 
has a code first note, indicating it cannot be used as a primary diagnosis code. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 88305 billed for date of service April 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31645 rendered on January 17, 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 31645-51-XS 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 31645 is "Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial." 
 
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 CPT code 31645 is not supported. The record does not state that a bronchoscopy with therapeutic aspiration of the bronchial tree was performed 
during this encounter. 
 
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 code 31645 rendered on January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision, benign lesion including margins, except skin 
tag (11046) provided on May 17, 2022. 
 
You asked the Plan to pay for the surgical service. You say that payment for this service should not be 
recouped. The Plan denied your request. The Plan says there is a more appropriate code for this service. 
 
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 11406 is excision, benign lesion including margins, 
except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 centimeters. 
 
We find that CPT code 11406 is not supported in the medical record. Specifically, the record clearly indicates 
that drainage of infected sebaceous cyst was performed, not an excision. Based on this information, we decided 
that Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan 
does not have to pay for the excision, benign lesion including margins, except skin tag (11046) provided on 
May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87501 billed for date of service January 23, 
2023.  
 
You asked the Plan to pay for procedure code 87501. The Plan denied your request. The Plan says payment for 
code 87501 is bundled into payment for code 87631. 
 
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, we have confirmed that code 87501 is a column II code to column I code 87631 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87501 billed for date of service January 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity is not demonstrated because there is insufficient documentation 
of reevaluation after a trial of non-surgical management. There is insufficient documentation of either 
worsening pain or radiographic progression despite a trial of optimal non-surgical management. There is no 
documentation of continuum of care for referral for evaluation of bone mineral density and osteoporosis 
education. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding a diagnosis of osteoporosis or treatment for osteoporosis. Additionally, there is no 
documentation of the worsening of pain, progression of the body height loss, greater than 25% vertebral body 
height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is no magnetic 
resonance imaging provided for review to corroborate the compression fracture at T12.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services are not medically necessary for the enrollee. 
 
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 there are no LTACH services needed that are not available in current setting and the 
enrollees condition is too acute for LTACH at this time. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95886 and 95913 rendered on January 25, 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 
the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95913: 
 
Nerve conduction studies; 13 or more 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 not supported by the medical records. Our reviewer found that the enrollee was referred for 
nerve conduction study, plus electromyography (EMG) of the bilateral lower extremities. The documentation 
supports that both of the denied were actually performed 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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 95886 and 95913 rendered on January 25, 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 the lab services (0326U) provided on March 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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. 
 
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 use of code 0326U is 
not supported by the records provided. Our reviewer found that that the medical records provided does not 
include sufficient documentation (interpretation and report) to validate that a "Targeted genomic sequence 
analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for 
sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor 
mutational burden" was performed. Therefore, this procedure 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (0326U) provided on March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is requiring inpatient level care with active attempts to wean from ventilator 
support and continued nutritional support with enteral feeds. The enrollee requires daily labs and physician 
oversight. The anticipated duration of acute medical needs would likely meet or exceed 25 additional days. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care.  The 
Plan denied your request. The Plan says the requested LTACH services are not medically necessary, 
reasonable, or appropriate for the diagnosis and condition of the enrollee at this time.  
 
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 the enrollee is receiving all indicated care at the current acute facility. There are no 
clear therapies that they would receive at the LTACH. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eyebrow tattoo provided on February 8, 2023. 
 
You asked the Plan to pay for the eyebrow tattoo. You say that the eyebrow tattoo is medically necessary due 
to losing your eyebrow hair from cancer treatment with chemotherapy. 
 
 The Plan denied your request. The Plan says the requested eyebrow tattoo is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 eyebrow tattoo. Our reviewer says that 
the requested eyebrow tattoo is cosmetic and not considered medically reasonable and necessary. Our reviewer 
found that the eyebrow tattooing should be considered as a cosmetic procedure that fails to meet Medicare coverage criteria, which states that a procedure must be furnished to improve the functioning of a "malformed 
body member" such as a breast after mastectomy. Eyebrow tattooing fails to reach this benchmark, as there are 
other means to improve eyebrow appearance, such as makeup, that may be less convenient, but would perform 
the same function. 
 
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 eyebrow tattoo have not been met. Therefore, we decided that the Plan does 
not have to pay for an eyebrow tattoo provided on February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection, third level, (64495) provided on 
May 23, 2023. 
 
You asked the Plan to pay for the facet joint injection. You say that this was medically necessary for the 
enrollee. The Plan denied your request. The Plan says the provider did not provide evidence of unique 
circumstances for a third level with sufficient documentation of medical necessity on appeal. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a 3 or 4-level procedure bilaterally may 
be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 facet joint injection. Our reviewer says that the facet joint injection at the third level is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate a unique circumstance that would warrant coverage for a facet joint 
injection at a third level. Therefore, the reviewer found that this injection 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 the facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the facet joint injection, third level, (64495) provided on May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0217 billed for dates of service February 8, 
2023, to March 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical literature shows the efficacy of the 
treatment. The Plan denied your request. The Plan says the service is not reasonable and necessary. 
 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 looked at the file and the rules. Code E0217 has not been established as reasonable and necessary. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code E0217 billed for dates of service 
February 8, 2023, to March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services related to end-stage renal disease (ESRD) provided 
from November 4, 2022, to November 30, 2022. 
 
You asked the Plan to pay for ESRD services. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says these services  
 
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 ESRD services have been met. 
Specifically, the records provided to the Plan were very limited. There were no records to indicate how the 
enrollee came to this provider, to show that these services were actually performed, or any physician notes to 
support the medical necessity of these services. Therefore, we decided that the Plan does not have to pay for 
services related to end-stage renal disease (ESRD) provided from November 4, 2022, to November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service February 3, 
2023, to March 4, 2023. 
 
You asked the Plan to pay for the billed services. You say that the unit reduces post-surgical complications. 
The Plan denied your request. The Plan says the code is not eligible for reimbursement. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0675 was billed for the prevention of deep vein thrombosis. Items that are used for a 
preventative service or function are excluded from coverage. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code E0675 billed for dates of service February 3, 2023, to March 4, 2023.