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

 
We decided that the Plan does not have to pay for anesthesia services (00532) provided on May 10, 2023. 
 
You asked the Plan to pay for anesthesia services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. Codes for unspecified side should 
rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it 
is not possible to obtain clarification. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of anesthesia services have not been met. Specifically, the services at issue were inappropriately 
reported with unspecified-side code C34.90, Malignant neoplasm of unspecified part of unspecified bronchus 
or lung. Therefore, we decided that the Plan does not have to pay for anesthesia services (00532) provided on 
May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99309) provided on June 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that place of service (POS) code 31 should be used 
with services for patients in a Part A covered stay and POS code 32 should be used with services for 
beneficiaries in a noncovered stay. 
 
We looked at the file and Medicare rules. As the facility claim was billed with the appropriate POS code (31) in 
this case, the claim in question should also be billed with POS code 31. It is inappropriate to billed POS code 
32 in this case. 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 (99309) provided on June 
12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5828, L5845, L5848). 
 
You asked the Plan to pre-approve the microprocessor knee. You say that this knee is medically necessary. The 
Plan denied your request. The Plan says this type of knee exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. 
 
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 microprocessor knee. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found the documentation does not reveal 
medical reasons that support that this patient's activities cannot be met with a mechanical knee. 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee (L5828, L5845, L5848).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service June 12, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code at issue is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99223 for date of service June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 25, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. 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 wound care supplies 
provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 an office visit provided 
on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ECG provided on January 10, 2023. 
 
You asked the Plan to waive the deductible for an ECG. You say that you thought this service was included in 
the annual wellness visit. 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. Your 
contract with the Plan says that there is a $100 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 You have been asked to pay $14.96 towards your $100 deductible for the MRI. The item or service you asked 
the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $100 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost 
sharing is a contractual obligation that had not been met at the time an ECG was received on January 10, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for an ECG provided on January 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of Integra skin substitute. 
 
You asked the Plan to pre-approve Integra skin substitute. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested 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 Integra skin substitute. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a stage IV sacral decubitus ulcer. The enrollee does not qualify for 
application of Integra skin substitute. Specifically, off-loading is not feasible, and bone is exposed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Integra skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve application of Integra skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
December 24, 2022, to December 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema/inflammation and post-surgical lymphedema by these services. The Plan denied your request. 
The Plan says per NCD guidelines, claims for E0675 is not a covered service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided December 24, 2022, to December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro orthosis is not the 
standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term 
outcomes for the enrollee. 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (38571) provided on July 28, 2023. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the code 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 38571 is surgical laparoscopy, with a bilateral total pelvic 
lymphadenectomy. 
 
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 surgical services. Our reviewer says that the records do 
not support the billed service. Our reviewer found while a bilateral lymph node dissection was planned, the documentation clearly states that this procedure was omitted due to intraoperative findings. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (38571) provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 30, 2023, to August 17, 
2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on March 30, 2023, to August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0673) provided on 
December 5, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
there is evidence of misrepresented services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0673) provided on December 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aflibercept. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the records show that the medication will be dispensed 
by the pharmacy on the patient's behalf. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Aflibercept.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision or removal of implanted spinal neurostimulator 
pulse generator or receiver (63688), and allografts (20930, 20936) provided on June 5, 2023.  
 
You asked the Plan to pay for the surgical services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 63688. The 
Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that 
Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. 
Additionally, we find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee 
Schedule. This means that procedure codes 20930 and 20936 are not separately payable. Based upon this 
information, we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we 
decided that the Plan does not have to pay for the revision or removal of implanted spinal neurostimulator pulse 
generator or receiver (63688), and allografts (20930, 20936) provided on June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided 
June 19, 2023. 
 
You asked the Plan to pay for the diagnostic service. You say that please review all included documents as 
services are medically necessary and appropriately coded. The Plan denied your request. The Plan says 
diagnosis code R42 is not a valid diagnosis code for CPT 93880. 
 
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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. 
 
We find that CPT code 93880 is not supported in the medical record. Specifically, per Local Coverage Article A52992, diagnosis code R42: dizziness and giddiness, is not listed as a diagnosis code that supports medical 
necessity for procedure code 93880. Based on this information, we decided that Medicare rules for coverage of 
the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the 
duplex scan of extracranial arteries (93880) provided June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that depend upon the hospital staff to verify eligibility 
and to obtain the proper authorization from the patients insurance. 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 an office visit provided 
on July 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that this procedure is considered experimental. It is the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.