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

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the medical records support medical 
necessity. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 86077 billed for date of 
service July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 
2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the performed procedure. 
The Plan denied your request. The Plan says that code 76641 has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 is supported. 
CPT code 76641 has an MUE value of 2. The claim shows that 1 unit of service was billed with the LT 
modifier, and 1 unit of service was billed with the RT modifier on another claim line. 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 code 76641 billed for date of service September 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98941) and the office visit (99204) provided from April 15, 2021, through August 26, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that the chiropractic services provided 
were medically necessary. The Plan denied your request. The Plan says that the routine chiropractic services 
provided are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that the 
services provided were not medically necessary. Our physician reviewer found that in this case, the records 
indicate that you have lumbar spondylosis. The records provided do not indicate an active treatment plan.   
The records submitted indicate that the services provided were considered maintenance therapy. The records 
provided do not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
services provided. The elements of the coverage criteria are not satisfied. 
 
 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 issue reimbursement for the chiropractic manipulative treatments (98941) and the office visit (99204) 
provided from April 15, 2021, through August 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve the transurethral waterjet ablation of prostate. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
attributable to benign prostatic hyperplasia (LUTS/BPH) will be considered reasonable and necessary when 
performed ONCE in patients with the indications listed in the Medicare Rules section. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transurethral waterjet ablation of prostate have not been met. Specifically, this enrollee is not 
under the age of 80. Therefore, we decided that the Plan does not have to pre-approve the transurethral waterjet 
ablation of prostate (0421T).
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 9, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. 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 of procedure code 99100 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 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test 
(PSA) (G0103) provided on August 22, 2022. 
 
You asked the Plan to pay for the PSA test. You say that your doctor said you needed this test. The Plan denied 
your request. The Plan says you have exceeded the frequency limit for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that screening PSA tests are covered at a frequency of 
once every 12 months for men who have attained age 50 (at least 11 months have passed following the month 
in which the last Medicare-covered screening prostate specific antigen test was performed). 
 
We looked at the file and Medicare rules. A PSA test was previously covered on May 27, 2022. Based on this information, we decided that Medicare rules for coverage of the PSA test have not been met. Therefore, we 
decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test (PSA) 
(G0103) provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on June 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the documentation did not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a current and valid physician order or relevant medical records which support 
medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment provided on June 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on July 23, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered for 
the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that cytogenetic studies are covered for the 
indications established in the applicable NCD.  
 
We looked at the file and Medicare rules. The requested cytogenetic study is not covered for dehydration. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the testing provided on July 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physical and occupational 
therapy for strengthening, endurance, balance, mobility, gait training, memory and problem solving. You say 
that the enrollee also requires 3 hours of therapy a day provided by a multidisciplinary team and can continue 
to benefit from high intensity therapy. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can safely be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rural health clinic visit (99214) provided on September 28, 
2022. 
 
You asked the Plan to pay for the rural health clinic visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the code was not billed with 
the required CG modifier. Based on this information, we decided that Medicare rules for coverage of the rural 
health clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for a rural health 
clinic visit (99214) provided on September 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a shoulder arthroplasty (23472-
AS) provided on August 4, 2022. 
 
You asked the Plan to pay for surgical assistant services. You say that this should be covered. The Plan denied 
your request. The Plan says the records do not document that this service was performed by the billed rendering 
provider. 
 
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 code 23472-AS is not supported in the medical record. Specifically, the records do not 
indicate that the billed rendering provider provided surgical assistant services. Other surgical assistants are 
indicated in the records. Based on this information, we decided that Medicare rules for coverage of surgical 
assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
assistant services on a shoulder arthroplasty (23472-AS) provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have SI joint pain (sacroiliitis). 
The requested SI joint RFA is considered experimental/investigational in nature due to wide variation in 
effectiveness reported in the medical literature. The services 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 sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0069) provided on May 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 G0069 is "Professional services for the administration of 
subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug 
administration calendar day in the individual's home, each 15 minutes". 
 
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 use of code G0069 is 
not supported by the records provided. Our reviewer found that the medical record does not include enough 
documentation to confirm this service was performed on May 4, 2022. Records include evaluation and 
management services, laboratory services, physician orders, a delivery ticket for 2020 and 2021, and a delivery 
ticket and compounding record for 2022. In this case, code G0069 and units of service 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (G0069) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided 
on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) 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 pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
are 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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI of the lumbar spine has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 22845, 22554, 22551, 
22853). 
 
You asked the Plan to pre-approve the spinal surgery. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are 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 the spinal 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records show that you are a current smoker and there 
is no documentation of smoking cessation. This is a contraindication to spine fusion surgery. 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve the spinal surgery (CPT code(s): 22845, 22554, 22551, 22853).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 99213. The Plan denied your request. The Plan says payment for 
code 99213 is bundled into payment for code 20610. 
 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 99213 
is a column II code to column I code 20610. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99213 billed for date of service August 19, 2022.