Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 96368 and 96375. We decided that the Plan does not 
have to pay for procedure codes 99214 and 99072.  
 
You asked the Plan to pay for the pain management services provided on August 30, 2022. The Plan says that 
the billed codes remain not supported. 
We decided that the Plan has to pay for procedure codes 96368 and 96375.  
 
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 96368 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary 
procedure). The definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance 
or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to 
code for primary procedure). 
 
We find that CPT codes are supported. The Plan denied as the codes required a primary code. CPT codes 
96368 and 96375 are add-on codes that are payable when billed with primary procedure code 96365, which the 
Plan has agreed to pay for on appeal. Based on this information, we decided that Medicare rules for coverage 
have been met. Therefore, we decided that the Plan has to pay for procedure codes 96368 and 96375 billed for 
date of service August 30, 2022.  
 
We also decided that the Plan does not have to pay for procedure codes 99214 and 99072. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. We find that CPT code 99214 is not supported in the medical 
record. The records show that the enrollee presented with her typical pain complaints. The records do not show 
that a level of moderate decision making was provided. Based on this information, we decided that Medicare 
rules for coverage have not been met. 
 
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. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
99214 and 99072 provided on August 30, 2022. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cardiovascular stress test, the positron emission tomography (PET) scan, the myocardial perfusion imaging, the rubidium rb-82 injection, and the regadenoson injection provided by an in-network provider on October 31, 2022.

You asked the Plan to waive the cost sharing for the stress test, the positron emission tomography (PET) scan, the myocardial perfusion imaging, and the injections. You say that you think that these services should be covered in full. 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 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services, which includes treadmill stress tests, a 20% coinsurance for in-network Medicare-covered radiological diagnostic services, which includes positron emission tomography (PET) scans, and nuclear studies, a 20% coinsurance for each in-network Medicare-covered medical supply, and a 20% coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer.

You have been asked to pay a $410.43 coinsurance for the stress test, the positron emission tomography (PET) scan, the myocardial perfusion imaging, and the rubidium rb-82 injection ($2052.17 allowed amount x .20 = $410.43). These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $49.18 coinsurance for the regadenoson injection ($245.92 allowed amount x .20 = $49.18). This item/service falls within the Medicare Part B prescription drugs benefit category.

You have been asked to pay a total cost share of $459.61 for the positron emission tomography (PET) scan, the myocardial perfusion imaging, and the injections. 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 cost sharing for the cardiovascular stress test, the positron emission tomography (PET) scan, the myocardial perfusion imaging, the rubidium rb-82 injection, and the regadenoson injection provided by an in-network provider on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a StabiLink interspinous process device 
(22842). 
 
You asked the Plan to pre-approve a StabiLink interspinous process device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 StabiLink interspinous process 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that StabiLink interspinous process device is experimental. More 
research is needed to demonstrate its safety and efficacy.  

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 StabiLink interspinous process device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of a StabiLink interspinous process device 
(22842).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pre-visit patient screening (D9912) and unspecified 
adjunctive procedure (D9999 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pre-visit patient screening (D9912) and unspecified adjunctive procedure (D9999 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that an authorization is on file for the date of 
service. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97010 billed for date of service November 22, 2022.
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 19, 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 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 84480. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481 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 84480 billed for date of service May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 (sales tax) billed for date of service 
October 24, 2022. 
 
You asked the Plan to pay for procedure code S9999. You say that your doctor prescribed this item and you 
would like reimbursement. 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 S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9999 (sales tax) billed for date of service October 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the denial. 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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicament dispensed in office for home use 
(D9630). 
 
You asked the Plan to pre-approve drugs or medicament dispensed in office for home use. You say that the 
services are necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
drugs or medicament dispensed in office for home use (D9630).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service July 23, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you would like the Plan to reconsider their 
denial of 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service July 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 provided from December 
16, 2021, to December 19, 2021. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. 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 supported 
as billed.  

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 procedure codes 99223 and 99233 
have been met. Medical records for dates of service December 16, 2021, December 18, 2021, and December 
19, 2021, were not provided for review. Therefore, we decided that the Plan does not have to pay for procedure 
codes 99223 and 99233 provided from December 16, 2021, to December 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unlisted special service (99199) 
provided on October 18, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as an 
itemized bill for this service has not been provided. 
 
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. Additionally, the Plan provides coverage for a 
chiropractic initial evaluation once per calendar year.  
 
The records show that the service at issue does not meet criteria for coverage. Specifically, Medicare rules say 
that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation.  

Additionally, the Plan contract provides supplemental coverage for a chiropractic initial evaluation once per 
calendar year. The Plan requested an itemized bill for the service provided in this case as a generic code was 
billed. An explanation of the service provided is necessary to determine if the service billed in this case meets 
criteria for payment. However, this information has not been provided to the Plan. Therefore, we decided that 
the Plan does not have to issue reimbursement for the unlisted special service (99199) provided on October 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on November 29, 2022.

You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of this testing.

The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FoundationOne CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on June 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making or must reach 30-39 minutes of total time (non-face to face and 
face to face total time) spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the documentation does not 
include the total time spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit coded 99214 provided on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate, 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for December 7, 
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 procedure codes 87899 and 87900 are 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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 
is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
We find that CPT codes 87899 and 87900 are not supported in the medical record. Specifically, the records do not document that infectious agent detection by immunoassay with direct optical observation was performed to 
support code 87899. There is no documentation of infectious agent drug susceptibility phenotype prediction 
was performed to support code 87900. There are more specific codes for the billed services. 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 procedure codes 87899 and 87900 billed for December 7, 2022.