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

 
We decided that the Plan does not have to pay for procedure code 95822 provide on March 28, 2022. 
 
You asked the Plan to pay for procedure code 95822. You say that you would like the Plan to reconsider their 
denial of payment. 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 code 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
We find that CPT code 95822 is not supported in the medical record. Specifically, the EEG was recording 
during surgery, not while the enrollee was in a coma or sleep. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95822 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95822 provide on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the billed diagnosis code D29.1 contains an Excludes1 
note for code N40. As code N40.1 was also billed, the claim is not payable as billed. 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 services provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro orthotic (L8702). 
 
You asked the Plan to pre-approve the Myopro orthotic. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically 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 Myopro orthotic. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 Myopro orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Myopro orthotic (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a consultation to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components.  
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and units, not 
one code and one unit of service as required by A58726. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the testing provided on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute 
IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pr-approve repetitive transcranial magnetic stimulation (TMS) 
treatment. 
 
You asked the Plan to pr-approve repetitive TMS treatment. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repetitive transcranial magnetic stimulation (rTMS) is 
only considered medically necessary in adults who have a confirmed diagnosis of major depressive disorder 
(MDD), single or recurrent episode and meet certain criteria 
 
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 pr-approve repetitive TMS treatment. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does have a 
diagnosis of major depressive disorder. The medical records that are available for review do not clearly support 
that the enrollee has had significant improvement in symptoms or function after previous TMS therapy. The 
requested maintenance TMS therapy is not medically 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 repetitive TMS treatment have not been met. Therefore, we decided that the 
Plan does not have to pr-approve repetitive transcranial magnetic stimulation (TMS) treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on November 30, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  Therefore, we decided that the Plan does 
not have to pay for the pneumatic compression device (PCD) and appliance provided on November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on December 
1, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 
87481, 87651 and 87653. 
 You asked the Plan to pay for the UTI panel. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on December 1, 2022, billed with codes 87500, 87641, 87798, 
87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
November 22, 2022, and billed with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 
87651, 87653, 87661, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on November 22, 2022, and billed with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 
87591, 87641, 87651, 87653, 87661, and 87798.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo. 
 
You asked the Plan to pre-approve Forteo. The Plan denied your request. The Plan says Forteo is on the self-
administered drug list and is excluded from coverage under Part B. 
 
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 Forteo.   
Benefits for Forteo 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the date of service does 
not align with the records provided. 
 
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 services have been met. The 
submitted documentation doe not contain medical records for the date of service in question. Therefore, we 
decided that the Plan does not have to pay for the drug testing services provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on February 8, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you have never had such a 
high cost share amount for this injection. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs.  
 
You have been asked to pay $304.48, which is 20% coinsurance of the allowed amount for the drug injection 
($1,522.42 allowed amount x 20% coinsurance = $304.48). This item/service falls within the Medicare Part B 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection provided on 
February 8, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the fracture treatment provided on December 15, 2022, billed with code 
23600. 
 
You asked the Plan to pay for the fracture treatment as billed. You say that the codes reported are appropriate 
for the treatment rendered. The Plan denied your request. The Plan says that code 23605 would be more 
appropriate than the billed code.  
 
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 23600 is closed treatment of proximal humeral (surgical 
or anatomical neck) fracture; without manipulation. 
 
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 fracture treatment as billed. Our reviewer says that the 
billed code is supported by the records.  Our reviewer found the procedure report documents "Humerus 
Fracture Treated With Immobilization, Easy-to-Read". Manipulation was not documented in the procedure 
report, as the fracture was only treated with arm sling. Therefore, CPT code 23600 would be appropriate code 
to report, rather than code 23605.   
 
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 fracture treatment as billed have been met. Therefore, we decided that the 
Plan has to pay for the fracture treatment provided on December 15, 2022, billed with code 23600.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350), unspecified periodontal procedure, by report 
(D4999), gingival irrigation - per quadrant (D4921) and oral hygiene instructions (D1330) provided on 
November 03, 2022, and November 30, 2022. 

You asked the Plan to pay for the dental services represented by codes D0330, D0350, D4999, D4921 and 
D1330. You say that the dental office told you they were in-network. The Plan denied your request. The Plan 
says any dental services not specifically identified in the Plan's 2023 EOC as covered are considered not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330), 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350), unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921) and 
oral hygiene instructions (D1330) provided on November 03, 2022, and November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option 
and accessories, including a center mount power elevating leg rest/platform (E1012).  
 
You asked the Plan to pre-approve a center mount power elevating leg rest/platform. You say that you do not 
agree with this denial. The Plan denied your request. The Plan says the provided records do not support that the 
requested power elevating leg rests are medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that elevating legrests may be covered when certain 
criteria have been 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 a center mount power elevating leg 
rest/platform. Our reviewer says that the requested center mount power elevating leg rest/platform is not 
medically necessary. Our physician reviewer found the provided documentation does not support that the 
enrollee has significant edema or the lower extremities. The documentation does not support that the approved 
wheelchair has a reclining back. The documentation also does not support that the enrollee has a 
musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee. 
Therefore, the reviewer found that the requested power elevating leg rest is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a center mount power elevating leg rest/platform have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option 
and accessories, including a center mount power elevating leg rest/platform (E1012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing (88312, 88305, 88112, 88301) provided on June 17, 2022.  
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing is recommended in the standard of practice guideline of major medical studies. The Plan denied 
your request. The Plan says there is no documentation or history of Barrett's esophagus.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not 
support that the WATS cytopathology and histopathology diagnostic testing provided on June 17, 2022, was 
medically reasonable and necessary for the enrollee in this case.  
 
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 WATS cytopathology and histopathology diagnostic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the WATS cytopathology and histopathology 
diagnostic testing (88312, 88305, 88112, 88301) provided on June 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT to be provided by an OON provider.  
 
You asked the Plan to pre-approve PT provided by an OON provider.. You say that it is too difficult for the 
enrollee to get to an in-network provider.  The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
PT to be provided by an OON provider.