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

 
We decided that the Plan does not have to pre-approve a knee arthroplasty. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says an active infection is a contraindication to surgery. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that dental caries or implant placement may reflect overall worse medical condition resulting in more 
complications and higher costs after total knee arthroplasty. Dental history screening preoperatively may assist 
arthroplasty surgeons in minimizing complications. Detailed documentation is not evident regarding the 
enrollee having undergone the needed dental work. There is an increased risk for complications with undergoing a total knee arthroplasty (with noted poor dentition.) There are no objective right knee findings to 
support the need for surgery despite the noted risk. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested right knee arthroplasty, 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 29999 for June 23, 
2021. 
 
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 assistant surgeon services are not covered. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 29999. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 these services. Our reviewer says that  Our 
physician reviewer found  
 
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 pay for the surgical services billed with code 29999 for June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 14, 
2022, to September 26, 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 were billed for one date of service. 
 
The Plan must follow Medicare rules. The rules say that providers must submit all information necessary to 
support the claims for necessary inpatient hospital services. 
 
We looked at the file and Medicare rules. The file shows that the claim for the services at issue was incorrectly 
billed with only one date of service. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital services rendered from September 14, 2022, to September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83721 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 83721. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 83721 is bundled into 
payment for code 80061. 
 
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 83721 
is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 83721 billed for date of service February 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 5, 2022, billed with 
codes 81292, 81294, 81295, 81297, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 5, 2022, billed with codes 81292, 81294, 81295, 81297, 81298, and 81317.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of thyroid stimulating hormone (84443) provided on 
December 20, 2022. 
 You asked the Plan to pay for assay of thyroid stimulating hormone. You say that this service was requested by 
the enrollee's physician. The Plan denied your request. The Plan says this service was provided as a screening 
which is not covered by Medicare. 
 
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, assay of thyroid stimulating hormone, was 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 pay for assay of thyroid stimulating hormone (84443) provided on December 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail two preferred products; Monovisc, 
Orthovisc, Synvisc, or Synvisc One first. 
 
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 Hyalgan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022. 
 You asked the Plan to pay for the home health services. You say that you already submitted the NOA. 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 8, 2022. The NOA, submitted on the correct form, was not 
received by the Plan until May 12, 2022. 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 the home health services provided from February 8, 2022, to March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 17, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service January 17, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the trifocal lens (V2300), frames (V2020), and 
progressive lens (V2781) provided on December 15, 2022. 
 
You asked the Plan to pay more for the trifocal lens, frames, and progressive lens. You say that you cannot 
afford to pay the amount of $289.95. You also say that if you had known you would be responsible for this 
whole amount, you would not have gotten the glasses. The Plan denied your request. The Plan says the 
maximum allowed under your benefit was exceeded. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 every two years for supplemental eyewear (retail or online) from any 
provider. 
 
 
 We looked at the file and the Plan's rules. The record shows that the full $150 allowance was applied toward 
this purchase on December 15, 2022, and your supplemental eyewear allowance has been exhausted. Based on 
this information, we decided that the Plan's rules for coverage of the trifocal lens, frames, and progressive lens 
have not been met. Therefore, we decided that the Plan does not have to pay more for the trifocal lens (V2300), 
frames (V2020), and progressive lens (V2781) provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87631) provided on June 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87631) provided on 
June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on November 22, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the colonoscopy. You say that this service should be covered. The Plan denied 
your request. The Plan says there were network providers available. 
 
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 colonoscopy provided on November 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices provided on January 11, 
2023. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that these devices were provided 
for use during the enrollee'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 items at issue in this appeal were for use outside of the home. Although these items 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 devices provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation is not sufficient to show the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on February 8, 
2023. 
 
You asked the Plan to pay for the outpatient office visit. You say that you are appealing the copay for your eye 
exam on February 8, 2023, because you thought this was a routine eye exam included in your plan. You also 
say that you scheduled this appointment as a routine eye exam, and told the office on the day of the exam it was 
routine and not medical. The Plan denied your request. The Plan says a medical eye exam was performed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you did not receive a routine eye exam. 
Specifically, you received a medical eye exam for lattice degeneration and cataract follow up. It was also noted 
the exam included a diagnosis/treatment of retinoschisis of the left eye. Based on this information, we decided 
that the Plan's rules for coverage of the outpatient office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient office visit (99214) provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on July 18, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for capsular contracture release (eg, Sever type procedure) 
rendered on January 19, 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 this is part of the primary procedure and not eligible for separate payment. 
 
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 23020 is "Capsular contracture release (eg, Sever type 
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 procedure detail cites the 
anterior and posterior capsule were assessed and they appeared to be contracted. The anterior capsule was 
released from the 1 down to the 6 oclock position and then the posterior capsule from the 9 down to the 6 
oclock position. Then the humeral head was easily able to be dislocated. This concluded the anterior and 
posterior capsule contracture release. Then the reverse shoulder continued by utilizing the intramedullary guide 
system and implant was placed. However, pre-operative details including markedly limited shoulder motion 
and details regarding capsular contracture were not clearly evident. Therefore, the records do not support CPT 
23020 as a separate and distinct procedure from CPT 23472. 
 
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 capsular contracture release (eg, Sever type procedure) rendered on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracranial bilateral study (93880) provided on 
December 24, 2022. 
 
  You asked the Plan to pay for the extracranial bilateral study. You say that as radiology physicians, you are 
classified as silent providers. You also say that you are not liable or have the authority to obtain authorizations 
and/or take the necessary measures to ensure medical criteria are met for enrollees by the facility. The Plan 
denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says 
that with the provided information, it cannot be determined how the enrollee came to the servicing provider, 
whether the services were performed as billed, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the extracranial bilateral study have 
been met. Medical records were not provided for this case. The record shows that the Plan made multiple 
attempts to obtain this information, but it was not received. Without medical records we are unable to 
determine if the criteria for coverage are met. Therefore, we decided that the Plan does not have to pay for the 
extracranial bilateral study (93880) provided on December 24, 2022.