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

 
We decided that the Plan does not have to pay for procedure codes 99072, A4556, A4557, A4649, S1015, 
S8301, and A9279 billed for date of service September 20, 2022. 
 
You asked the Plan to pay for procedure codes 99072, A4556, A4557, A4649, S1015, S8301, and A9279. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says the services are not covered as billed. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable.  
 
We find that procedure codes A4556, A4557, and A4649 have a status code of P on the Physician Fee Schedule 
and no separate payment is made for these codes under the fee schedule as payment is bundled into the 
payment for the services to which these codes are incident to. 
 
Lastly, we find that procedure codes S1015, S8301, and A9279 have a Status Indicator of I on the Physician 
Fee Schedule. This means that procedure codes S1015, S8301, and A9279 are not valid for Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99072, A4556, 
A4557, A4649, S1015, S8301, and A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99072, A4556, A4557, A4649, S1015, S8301, and A9279 billed for date of 
service September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are too complex for 
a skilled nursing facility, as they are at a high risk for poor outcome if they are discharged to a lower level of 
care. You say that the enrollee will require daily physician assessment, daily lab monitoring, strict intake, and 
output monitoring. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can receive the care they need in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain fused to high noble metal (D6240) 
provided on October 25, 2022. 
 
You asked the Plan to pay for the pontic - porcelain fused to high noble metal (D6240). You say that you are 
asking for the Plan to help with 25% of the amount billed which would aid you considerably. The Plan denied 
your request. The Plan says this service is not covered under the benefit package. 
 
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 the pontic 
- porcelain fused to high noble metal (D6240) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration for your 
share of the services provided. The Plan denied your request. The Plan says your benefit for the requested item 
or service 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 your benefit for the intraoral - periapical each additional radiographic image (D0230) was exhausted on 
date of service October 10, 2022 of this claim, intraoral - periapical first radiographic image (D0220).  Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each additional 
radiographic image (D0230), and periodic oral evaluation - established patient (D0120) provided on October 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0245U and 88381 billed for date of service 
April 27, 2022. 
 
You asked the Plan to pay for procedure codes 0245U and 88381. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 0245U is 
bundled into payment for code 0018U. Also, the medical records do not support the billing of code 88381. 
 
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 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II code is therefore not 
payable.  
 
Furthermore, the CPT Code Manual definition of code 88381 is Microdissection (ie, sample preparation of 
microscopically identified target), manual. We find that CPT code 88381 is not supported in the medical 
record. Specifically, the medical records do not show a manual microdissection was performed. 
 
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 codes 0245U and 88381 billed for date of service April 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97010 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional stationary oxygen concentrator and a 
portable oxygen concentrator. 
 
You asked the Plan to pre-approve an additional stationary oxygen concentrator and a portable oxygen 
concentrator. 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 must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator and a portable oxygen concentrator. The 
authorization for your existing equipment is valid from March 15, 2021 through March 14, 2024. Therefore, we 
decided that the Plan does not have to pre-approve an additional stationary oxygen concentrator and a portable 
oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that the records provided support 
the need for bone marrow aspirate services. The Plan denied your request. The Plan says the clinical value and 
effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the 
peer-reviewed 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 bone marrow aspirate services. Our 
reviewer says that bone marrow aspirate services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental when used as bone graft material. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the foot 
 
You asked the Plan to pre-approve the MRI of the foot. You say that an MRI of the ankle and foot would help 
you further evaluate the enrollee. You say that the records provided support the need for the requested MRI 
services. The Plan denied your request. The Plan says that the provider did not document any reason or 
diagnosis to obtain an MRI of the foot, other than pain which was not documented. The Plan says that an x-ray 
of the right foot showed no fracture, degenerative joint disease, pes planus and hallux deformity, all of which 
can attribute to pain and does not warrant further evaluation with an MRI of the foot. The Plan says that an 
MRI of the foot is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the foot. Our reviewer says 
that the requested MRI of the foot is medically reasonable and necessary. Our physician reviewer found the 
enrollee has hallux valgus and importantly has pes planus deformity as well.  As such it is important to evaluate 
the spring ligament as well as the attachment of the posterior tibialis tendon, a commonly ruptured structure in 
pes planus deformities. 
 
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 MRI of the foot have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) of the foot  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on May 19, 2022.

You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit provided on May 23, 2022. 
 
You asked the Plan to reimburse you for the office visit. You say that your insurance card says, "no referral 
required". The Plan denied your request. The Plan says you did not provide proof of payment. 
 
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 provided to determine whether payment is due and the amount of payment for the office visit 
provided on May 23, 2022. You have not provided proof of payment. Therefore, we decided that the Plan does 
not have to reimburse you for the office visit provided on May 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray billed with code 71046 for September 18, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71046 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 71046 is radiologic examination, chest; 2 views. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, there is no documentation of 
an x-ray of the chest with two views. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
billed with code 71046 for September 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, light module, LED, edge, bracket assembly (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessory. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the light assembly does not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the wheelchair component or accessory, not otherwise specified, light module, LED, edge, bracket 
assembly (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic/swing phase control (L5830), a stand 
flexion feature (L5845), a knee extension assist (L5850), and a friction swing phase control (L5616).  
You asked the Plan to pre-approve codes L5830, L5845, L5850, and L5616. You say that the items which 
remain in dispute are medically necessary. The Plan denied your request. The Plan says there are no notes that 
show the enrollee has advanced to K3 ambulatory function. The Plan says that the enrollee's needs can be met 
with a K2 knee. The Plan says that there is no clear documentation as to why the items which remain in dispute 
are needed. 
 
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 codes L5830, L5845, L5850, and 
L5616. Our reviewer says that the items which remain in dispute are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do support that the enrollee is at a functional 
level of K1 or above. The records do not support that the enrollee is at a functional level of K3 and above.  A 
January 9, 2023, evaluation for a new prosthesis states the enrollee has been less mobile due to other 
conditions. The enrollee uses assistive devices to ambulate and a wheelchair. The items which remain in 
dispute exceed the enrollee's medical needs as the documentation does not support that the enrollee requires 
these features. The enrollee's needs can be met with a less complex K2 level 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 codes L5830, L5845, L5850, and L5616 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic/swing phase control (L5830), a stand flexion 
feature (L5845), a knee extension assist (L5850), and a friction swing phase control (L5616).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable 
system (L5910). 
 
You asked the Plan to pre-approve an alignable system. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested system cannot be used with this preparatory prosthesis. 
Medicare Guidance says that the alignable system is not reasonable and necessary for a preparatory prosthesis. 
 
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 an alignable system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided records from your treating physician do not document medical necessity of 
the alignable system. A prescription is not considered to be part of the medical record. Medical information 
intended to demonstrate compliance with coverage criteria may be included on the prescription but must be 
corroborated by information contained in the medical record. Your medical record must contain sufficient 
documentation of your medical condition to substantiate the necessity for the type and quantity of items 
ordered and for the frequency of use or replacement (if applicable). The information should include your 
diagnosis and other pertinent information including, but not limited to, duration of your condition, clinical 
course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc." 
 
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 alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal system, below knee, alignable system (L5910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 15, 2022.