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

 
We decided that the Plan does not have to pre-approve genicular artery embolization coded with procedure 
codes 37243 36245, 36246, 75625, 76937, 99152 and 99153. 
 
You asked the Plan to pre-approve the surgical procedure. You say that this procedure has denied because it 
has been deemed not medically necessary and you are writing to appeal this denial. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. there are not 
enough studies on geniculate artery embolization for treatment of knee osteoarthritis to show it is safe and 
effective. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for bilateral primary osteoarthritis of the knee, chronic 
pain, pain in the right knee, and pain in the left knee and is being seen for consultation for genicular artery 
embolization. However, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be 
promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or 
better than standard treatments for knee osteoarthritis. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
genicular artery embolization, 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular artery embolization coded with procedure codes 37243 36245, 36246, 
75625, 76937, 99152 and 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 31, 2022, billed with 
codes 81291, 81335, 81227, 81225, 81328, 81231, 81355, 81232, 81408, 81240, 81241, and 81230. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
August 31, 2022, billed with codes 81291, 81335, 81227, 81225, 81328, 81231, 81355, 81232, 81408, 81240, 
81241, and 81230.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you have been in use of a knee scooter for the 
last five years due to an ulcerated wound on the bottom of your foot. You say that the knee scooter allows you 
to keep your independence at home. You also say that your current scooter is in need of repairs that cannot be 
replaced thus a new scooter is needed. The Plan denied your request. The Plan says the requested device does 
not have a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Additionally, the 
record does not show there was a previously paid claim for a knee scooter. Therefore, we decided that the Plan 
does not have to pre-approve a knee scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tumor excision (21933). 
 
You asked the Plan to pre-approve a tumor excision. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a tumor excision. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that supports that the tumor excision at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this 
case do not document any recent enlargement, associated pain, discomfort or drainage from the mass; the enrollee has no systemic symptoms and nothing in the physician's notes suggests that the mass is causing the 
enrollee's lower extremity tingling sensation. There are no imaging studies demonstrating complications or 
nerve impingement caused by the mass. 
 
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 tumor excision have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a tumor excision (21933).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code(s) 95816 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code(s) 95816. You say that this claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable without the appropriate modifier billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95816. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 95816. Based on this information, 
we decided that Medicare rules for coverage of procedure code 95816 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 95816 billed for date of service September 19, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 19, 2021, billed 
with procedure codes 95955, 95885, 95937, and 95908. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) codes 95955, 95885, 95937, and 
95908 remain unsupported. 
 
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 95955, 95885, 95937, and 95908 is 
electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery), needle electromyography, 
each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited (List separately in addition to code for primary procedure), neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method, Nerve conduction studies; 3-
4 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 medical services. Our reviewer says that the 
documentation does not support procedure codes 95955, 95885, 95937, and 95908. Our reviewer found that 
regarding procedure code 95955, the procedure report documents, neuromonitoring service provided for 
decompression (Laminectomy, Laminoplasty, Foraminotomy, Facetectomy). In this procedure, the provider 
uses electroencephalographic monitoring of a member during non-intracranial surgery like cardiac surgery or 
carotid stenting. 
 
Regarding procedure code 95885, in this case, nerve conduction study is not documented in the procedure 
report, and therefore this procedure cannot be verified. 
 
Regarding procedure code 95937, the procedure report does not include documentation of neuromuscular 
junction testing, was unable to cite report as this procedure was not found in medical record.  
 
Regarding procedure code 95908, in this case pedicle screw stimulation would not be reported with nerve 
conduction, amplitude and latency/velocity study, 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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on August 19, 2021, billed with procedure codes 95955, 
95885, 95937, and 95908.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular testing (81479) provided on November 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the molecular testing. You say that the enrollee's physician ordered molecular 
testing as part of their treatment plan. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 molecular testing (81479) provided on 
November 26, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone tablets. 
 
You asked the Plan to pre-approve Prednisone tablets. 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 Prednisone tablets.   
Benefits for Prednisone tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the pontics (D6245), the retainer crowns (D6740), and 
the extractions (D7140) for tooth #22, #23, #24, #25, #26, and #27 provided by an out-of-network provider on 
January 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the denied dental claim. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. Also, your dental benefit for 
the year has already been exhausted. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows for January 16, 2023, the Plan paid $1,902 for dental services. On March 22, 2023, which was processed 
prior to the claim for January 16, 2023, the Plan paid $98 for dental services. For the year of 2023 the Plan paid 
$2,000 ($1,902 paid + $98 paid) for dental services; therefore, your annual dental maximum benefit for the 
year of 2023 was exhausted on the date of service of January 16, 2023. You have also been asked to pay the 
difference between the out-of-network providers charges and the Plans payment. 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 pay more for the pontics (D6245), the retainer crowns (D6740), and the extractions (D7140) 
for tooth #22, #23, #24, #25, #26, and #27 provided by an out-of-network provider on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth consultation billed with code G0427 for 
November 22, 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 claim was billed with the incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that procedure code G0427 was incorrectly billed with 
POS code 23 for an emergency room and not the required 02 code. Therefore, we decided that the Plan does 
not have to pay for the telehealth consultation billed with code G0427 for November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849) provided on December 3, 
2022. 
 
You asked the Plan to pay for the traction equipment. You say that you needed this for damaged discs in your 
neck. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for items of DME, A/B MACs (HHH) and DME 
MACs pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 
months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the traction equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for the traction equipment (E0849) provided on December 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93319 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code 93319. You say that you billed this code with modifiers to allow 
for separate payment. The Plan denied your request. The Plan says payment for code 93319 is bundled into 
payment for code 93325. 
 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 93319 
is a column II code to column I code 93325 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 93319 billed for date of service November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx (0242U) provided on May 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the diagnosis from Guardant360 enabled the 
doctor to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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 Guardant360 CDx (0242U) provided on May 16, 
2021, 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 surgical dressing provided on December 8, 2022. 
 
You asked the Plan to pay for the surgical dressings. You say that these surgical dressings are sent to the 
enrollee's home and are not used in the office. This means that they can be separately paid. The Plan denied 
your request. The Plan says this claim is not payable to a physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
 
 This claim for surgical dressings is covered when furnished by a supplier enrolled in Medicare as a durable 
medical equipment (DME) supplier. The National Provider Identification (NPI) number with which this claim 
was billed is for a physician's office. This cannot be paid unless billed under an NPI that is enrolled as a DME 
supplier. As such, the denial of payment is supported. Therefore, we decided that the Plan does not have to pay 
for the surgical dressing provided on December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography provided on October 24, 2022. 
 
You asked the Plan to pay for the screening mammography. You say that this was not a new mammogram, it 
was a follow up procedure from your April mammogram. The Plan denied your request. The Plan says we have 
paid the maximum amount covered by your Plan for this service. 
 
The Plan contract says that the Plan covers one screening mammogram each calendar year for women age 40 
and older. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit of one 
screening mammogram each calendar year. Therefore, we decided that the Plan does not have to pay for a 
screening mammography provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged services (procedure code 99356) rendered on 
December 5, 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 the documents do not support this level of care. 
 
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 99356 is "Prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to 
code for inpatient or observation Evaluation and Management service)." 
 
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 medical records do not 
indicate any additional time above and beyond to be able to bill CPT 99356. 
 
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 prolonged services (procedure code 99356) rendered on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service November 29, 2022.