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

 
We decided that the Plan does not have to pay for testing services provided on May 19, 2023, to May 24, 2023, 
billed with procedure codes 95715 and 95700. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95715 and 95700 is electroencephalogram with video 
(VEEG), review of data, technical description by electroencephalogram (EEG) technologist, each increment of 
12-26 hours; with intermittent monitoring and maintenance, and electroencephalogram (EEG) continuous 
recording, with video when performed, setup, patient education, and takedown when performed, administered 
in person by EEG technologist, minimum of 8 channels.  
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found procedure 95715 was not found in 
medical record submitted. Procedure 95700 is not supported as the date of service billed cannot be verified by 
documentation submitted. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on May 19, 2023, to May 24, 2023, billed with 
procedure codes 95715 and 95700.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 7, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been going to the chiropractor for 30 years 
as it is more convenient for you to go to this one, as he is closer. The Plan denied your request. The Plan says 
that your contract states that chiropractic services other than the manual subluxation of the spine are not 
covered.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on June 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NeuroTrax testing coded as 96132. 
 
You asked the Plan to pre-approve NeuroTrax testing coded as 96132. You say that the patient needs a 
comprehensive cognitive assessment (NeuroTrax) to establish their diagnosis and initiate treatment. You also 
say that this test is medically necessary. The Plan denied your request. The Plan says the testing as requested is 
not reasonable or necessary at this time for a NeuroTrax automated test. 
 
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 NeuroTrax testing coded as 96132. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
neuropsychological testing is indicated for the evaluation of cognitive symptoms including memory loss as 
documented for the patient in this case. The Provided records do not clarify that the NeuroTrax testing will be 
performed by a psychiatrist or other physician trained in the treatment of mental illness, or a clinical 
psychologist, or a clinical social worker, or a clinical nurse specialist or other nurse with special training and/or 
experience in psychiatric nursing as required by the LCD. Our reviewer found that code 96132 represents 
neuropsychological testing evaluation services by a physician or other qualified health care professional, 
including integration of patient data, interpretation of standardized test results and clinical data, clinical 
decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or 
caregiver(s), when performed; first hour. Our physician reviewer also found that the provided records in this 
case do not clarify that the NeuroTrax testing meets this definition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NeuroTrax testing coded as 96132 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve NeuroTrax testing coded as 96132.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
iliac artery, unilateral, initial vessel (37221). 
 
You asked the Plan to pre-approve the revascularization procedure. You say that this is medically necessary 
based on the enrollee's symptoms as well as the positive vascular studies. The Plan denied your request. The 
Plan says the clinical value and effectiveness of the endovascular revascularization in the setting of a normal 
physical examination of the leg pulses and the absence of limb threatening ischemia has not been documented 
in the medical literature. 
 
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 revascularization procedure. Our 
reviewer says that the requested revascularization for the iliac artery is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not document necessity of another 
procedure on the right iliac artery given the stenting procedure one month prior. Therefore, the reviewer found 
that the requested revascularization procedure 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 revascularization procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, 
unilateral, initial vessel (37221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on June 5, 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 does not meet coding standards. 
 
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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 report describes a 
Prolia injection. The documentation does not support chemotherapy administration. There is a more specific code that should be reported for the documented services. 
 
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 96401 rendered on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on May 29, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for medication assisted 
treatment, and a take home supply of methadone provided on May 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342, & 88344 provided on March 21, 
2023. 
 
You asked the Plan to pay for procedure codes 88342, & 88344. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are not separately payable. 
 
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 codes 88342, & 88344 are not supported in the medical record. Specifically, code 88342 has 
a bundled relationship with codes 88344. Code 88344 is inclusive to code 88360 which was also billed. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 88342, & 88344 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88342, & 88344 
provided on March 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on May 23, 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 the billed code 99285 is not substantiated by the clinical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the records do not support an 
appropriate level of history and physical exam. The records do not support a high level of medical decision 
making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 13, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that you went to get results 
from previous blood work tests but the provider did not have the results at that time and you were sent home 
after paying copay. 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 a $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 copayment for an office visit provided on June 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 11, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on May 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-lab polysomnography (95811 x2). 
 
  You asked the Plan to pre-approve an in-lab polysomnography. You say that the patient has failed a trial of at-
home auto-positive airway pressure therapy, and you believe an in-lab sleep study with an attending sleep 
technician is necessary to establish a concrete reference for perfecting their machine settings. You also say that 
this is required for you to appropriately attempt to improve the patient's sleep apnea conditions. The Plan 
denied your request. The Plan says a repeat study is not considered medically necessary for durable medical 
equipment replacement. 
 
The Plan follows Medicare rules. Medicare rules say that a Type I Polysomnography (PSG) is covered when 
used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and 
symptoms indicative of OSA if performed attended in a sleep lab facility. 
 
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 an in-lab polysomnography. Our 
reviewer says that this request is not medically necessary. Our physician reviewer found the patient had a home 
sleep study performed and did not show substantial apnea-hypopnea index (AHI) or failure of resolution of 
OSA. The patient has also had a compliance study which supports the use of CPAP and treatment of OSA. Our 
reviewer also found that further in lab study not indicated per LCD and documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an in-lab polysomnography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an in-lab polysomnography (95811 x2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sleep study provided on March 11, 
2023. 
 
You asked the Plan to waive the copayment for the sleep study. You say that you are requesting reconsideration 
stating you are appealing the entire charge because you feel the sleep study was done incorrectly. You feel the 
company with the machine is ripping people off. 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 a $100 
copayment for outpatient hospital services. 
 
You have been asked to pay a $100 copayment for the sleep study. This item/service falls within the outpatient hospital services 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 copayment for the sleep study 
provided on March 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve supplies for a continuous glucose monitor (A4239). 
 
You asked the Plan to pre-approve the supplies for a continuous glucose monitor. You say that the item is 
medically necessary. The Plan denied your request. The Plan says that records show the enrollee uses a phone 
to check the data and therefore coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if a beneficiary never uses a DME receiver or 
insulin infusion pump to display CGM glucose data, the supply allowance is not covered by Medicare. Rules 
also state that Medicare coverage of a CGM system supply allowance is available when a beneficiary uses a 
durable CGM receiver on some days to review their glucose data but uses a non-DME device on other days. 
 
We looked at the file and Medicare rules. While the records show that the enrollee does use their phone to 
review the data, the records also show that a stand-alone reader was approved. The records do not clearly state 
that the enrollee never uses a stand-alone reader. Based on this information, we decided that Medicare rules for 
coverage of the supplies for a continuous glucose monitor have been met. Therefore, we decided that the Plan 
has to pre-approve supplies for a continuous glucose monitor (A4239).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 rendered on April 4, 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 Current Procedural Terminology (CPT) code 93229 (1 units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93229 is "External mobile cardiovascular telemetry with 
electrocardiographic (ECG) recording, concurrent computerized real time data analysis and greater than 24 
hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional." 
 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 there is no evidence that the 
ambulatory ECG monitoring supports use of mobile cardiac outpatient telemetry (MCOT monitor code 93229. 
In summary, there is insufficient documentation to support the requested MCOT monitor code 93229. 
 
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 93229 rendered on April 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network skin biopsy procedure 
provided on February 24, 2023. 
 
You asked the Plan to waive the copayment for an in-network skin biopsy procedure. You say that you do not 
feel you should owe this copayment. 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 a $250 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $250 copayment for an in-network skin biopsy procedure. This item/service falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 copayment for an in-
network skin biopsy procedure provided on February 24, 2023.