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

 
We decided that the Plan does not have to pay for procedure codes 43242, 43266, 43245 and 43240 billed for 
date of service April 21, 2022. 
 
You asked the Plan to pay for procedure codes 43242, 43266, 43245 and 43240. You say that these services 
were reported correctly. The Plan denied your request. The Plan says these codes were not reported 
appropriately. 
 
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 43242 is a column II code to column I code 43240; code 43266 is a 
column II code to column I code 43240; and code 43245 is a column II code to column I code 43266. Each of 
these code pairs has a modifier indicator of 0. The column II codes are therefore not payable. Based on the 
claim submitted, Medicare billing criteria have not been met for procedure codes 43242, 43266 and 43245. 
 
In addition, the CPT Code Manual definition of code 43240 is eshophagogastroduodenoscopy, flexible, 
transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage 
catheter(s)/stent(s), when performed, and endoscopic ultrasound, when performed. 
 
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 procedure code 43240. Our reviewer says that this code is 
not supported by the medical record. Our reviewer found the operative report does not include documentation 
of a drainage of pseudocyst. The operative report states, "...due to focal narrowing noted at the sweep, dilation 
was performed at this area to 15mm; however, there was significant amount of resistance felt." In this case, 
code 43240 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 43242, 43266, 43245 and 43240 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 43242, 43266, 43245 and 43240 billed for 
date of service April 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 2, 2022, billed 
with code 95937. 
 
You asked the Plan to pay for the services as billed. You say that the services should be paid as billed. The Plan 
denied your request. The Plan says the claim was approved for payment except for 95937 which 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 as billed. Our reviewer says that the 
documentation does not support the use of this code. Our reviewer found the enrollee was treated with 
intraoperative neurophysiology monitoring during spinal surgery which includes neuromuscular junction 
testing (Train-of-Four testing). The use of 95937 to bill separately for this service is not appropriate. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on February 2, 2022, billed with code 95937.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. 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 stress testing without cardiac imaging will be 
considered medically reasonable and necessary under certain circumstances. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence 
provided that would support the need for radionuclide stress testing. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 6, 2022, by an
out-of-network provider.

You asked the Plan to pay for the physician's services. You say that it is the responsibility of the nursing facility to get authorizations for their patients. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless preauthorized.

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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 6, 2022, by an
out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 22, 
2022. You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 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 
99100 billed for date of service June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from October 15, 2021, to June 
21, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that the documents support the claim was billed 
appropriately, and you would like this claim to be reprocessed for payment. The Plan denied your request. The 
Plan says an authorization is required for services performed by a non-contracted provider.  
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 inpatient stay have been met. 
Medical records were not provided for this case for the October 15, 2021, to June 21, 2022 dates of service. 
The record shows that the Plan requested this documentation, but it was not received. Without medical records 
we are unable to determine if the services provided were medically necessary. Therefore, we decided that the 
Plan does not have to pay for the inpatient stay provided from October 15, 2021, to June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
30, 2022.  

You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 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 
99100 billed for date of service September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says 7 visits remain denied due to not being medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the seven additional home health physical therapy 
visits meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound imaging provided on September 1, 2022, 
billed with code 76998. 
 
You asked the Plan to pay for the imaging as billed. You say that it is felt that this should be covered. The Plan 
denied your request. The Plan says the code 76998 was 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 76998 is Ultrasonic guidance, intraoperative. 
 
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 imaging as billed. Our reviewer says that 
the use of code 76998 is not supported. Our reviewer found the operative report did not include documentation 
of intraoperative ultrasonic guidance, as an independent procedure. Therefore, this code cannot be verified. 
 
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 imaging as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound imaging provided on September 1, 2022, billed with code 76998.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 4, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be responsible to 
pay this. 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 a primary care visit.  

 You have been asked to pay $25 for an office visit. This item/service falls within the primary care visit 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 October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332), 
prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), bitewings - four 
radiographic images (D0274), intraoral - periapical first radiographic image (D0220) provided on January 26, 
2021, and June 28, 2021. 
 
You asked the Plan to pay for codes D2332, D1110, D0120, D0274, and D0220 provided on January 26, 2021, 
and June 28, 2021. You say that you have faxed and mailed your appeal request several times. The Plan denied 
your request. The Plan says the claims were not received within the allowed 12 months from the date of 
service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental codes D2332, D1110, D0120, D0274, and D0220 provided on 
January 26, 2021, and June 28, 2021 was not filed until October 21, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for codes D2332, D1110, D0120, D0274, and D0220 provided on January 26, 2021, and 
June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 86038-59, 80048-59, 85025-
59, 80076-59, 86695-59, 86696-59 and 87389-59 provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 billed with codes 86038-59, 80048-59, 85025-59, 80076-59, 
86695-59, 86696-59 and 87389-59 provided on July 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided on January 3, 2022. 
 
You asked the Plan to pay for the ambulance supplies. The Plan denied your request. The Plan says the routine 
disposable supplies and unlisted ambulance services are not covered by Original Medicare. 

The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 3, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. 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. 
 
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. 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 0245U billed for date of service February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 800 further units of Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has quadriplegic cerebral 
palsy and contracture of muscle of multiple sites. The records state that 600 units of Botox per treatment have 
been helping the enrollee loosen her tight and contracted muscles. The Medicare criteria for coverage state that 
the maximum cumulative dose should not exceed 400 units in a three month interval. The requested units every 
12 weeks are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 800 further units of Botox.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 96365 and 96374-59 for 
September 6, 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 the services are not covered. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. 
 
We find that CPT code 96365 is not supported in the medical record. Specifically, there is no documentation of 
the time over which the infusion was administered. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met.  
 
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 96374 is a column II code to column I code 
96365. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not 
supported as a separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria 
have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the services billed with codes 96365 and 96374-59 
for September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
August 15, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
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 was billed with Place of Service (POS) code 24, indicating use at an ambulatory 
surgical center. The item is for use outside of the home in this case. 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 pneumatic compression devices (E0675, E0673) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to crown 
(D2954) and the other drugs or medicaments (D9630x11). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown (D2954) and the other 
drugs or medicaments (D9630x11). You say that the cost of the temporary dentures is $1,900 and you cannot 
afford to pay. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 pre-approve the 
prefabricated post and core in addition to crown (D2954) and the other drugs or medicaments (D9630x11).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pay for an 
unspecified removable prosthodontic procedure (D5899) provided on October 10, 2022.